ASSESSMENT OF THE
POTENTIAL IMPACT OF
REGULATED MARIJUANA IN
NEW YORK STATE

 

 

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Table of Contents
Department of Health Charge ....................................................................................................................................3
Review Process ...........................................................................................................................................................3
Introduction ................................................................................................................................................................3
Findings.......................................................................................................................................................................5
I. Health ......................................................................................................................................................................5
II. Criminal Justice and Public Safety ....................................................................................................................... 11
III. Economic Estimates ........................................................................................................................................... 16
IV. Education............................................................................................................................................................ 21
V. Impact of Legalization in Surrounding States...................................................................................................... 22
VI. Implementation.................................................................................................................................................. 23
VI. Conclusion .......................................................................................................................................................... 27
Appendix A: Figures, Graphs and Charts ................................................................................................................. 28
Figure 1: Map of State Marijuana Policies.............................................................................................. 28
Figure 2: Past Month Marijuana Use, Aged 12-17, New York ................................................................ 29
Figure 3: Past Month Marijuana Use, Aged 18+, New York ................................................................... 29
Figure 4: Colorado Economic Development and Job Creation ............................................................... 30
Figure 5: Marijuana Tax Revenue Usage in Colorado............................................................................. 31
Appendix B: Annotated Bibliography ...................................................................................................................... 32
Introduction ............................................................................................................................................ 32
Health ..................................................................................................................................................... 32
Criminal Justice and Public Safety .......................................................................................................... 43
Economic Estimates................................................................................................................................ 46
Education ................................................................................................................................................ 49
Appendix C: Comparative Review of State Laws Legalizing Regulated Marijuana Use........................................... 56
References ............................................................................................................................................................... 70

ii

 Taxation and Finance, and the Department of
Transportation.

Charge
In his January 2018 budget address, Governor
Andrew M. Cuomo called for an assessment of the
possible impact of regulating marijuana in New York
State (NYS). The Governor directed NYS agencies to
evaluate the health, public safety, and economic
impact of legalizing marijuana. The experience of
legalized marijuana in surrounding states was
identified as an important issue to consider in the
impact assessment.

Notably, some issues associated with regulating
marijuana have been studied more thoroughly than
others. In addition, relevant stakeholders with
differing viewpoints have weighed in on the
potential impact of legalizing marijuana. To ensure
a comprehensive assessment, data from a variety of
sources were acquired. Given the variety of sources
utilized and the breadth of information contained in
this report, some areas of potential impact contain
discordant findings or viewpoints.

Review Process

Introduction

Pursuant to the Governor’s charge, a thorough
review was conducted of the health, criminal justice
and public safety, economic, and educational
impacts of a regulated marijuana program in NYS.
The assessment included an examination of the
implications of marijuana legalization that has
recently occurred in surrounding jurisdictions. This
is particularly important because the status quo in
NYS is changing as the State shares borders with
some jurisdictions that have legalized marijuana
and some that are likely to legalize soon.

Marijuana can be consumed by inhalation (smoking
and vaporizingI), oral consumption and topicals. It
contains a mix of THCII, cannabidiol (CBD)III,
terpenes,IV and other compounds.
Marijuana is easily accessible in the unregulated
market. A 2017 Marist Poll showed that 52 percent
of Americans 18 years of age or older have tried
marijuana at some point in their lives, and 44
percent of these individuals currently use it.1
Estimates from the National Survey on Drug Use
and Health (NSDUH) indicate that one in ten New
Yorkers used marijuana in the last month.2 The
status quo (i.e., criminalization of marijuana) has
not curbed marijuana use and has, in fact, led to
unintended consequences, such as the
disproportionate criminalization and incarceration
of certain racial and ethnic groups that has a
negative impact on families and communities.

This impact assessment involved a public health
approach to examining the benefits and risks
associated with legalizing marijuana in NYS as
compared to maintaining the status quo. In
developing the impact assessment, an extensive
analysis of peer-reviewed literature was conducted,
and information was obtained from jurisdictions
that have legalized marijuana. In addition, experts
in State agencies were consulted, including the
Department of Health (DOH), the Office of Mental
Health, the Office of Alcoholism and Substance
Abuse Services, the NYS Police, the Office of
Children and Family Services, the Department of

From the late 1800s until the 1930s, marijuana was
generally considered a benign, medically efficacious
substance that was sold in pharmacies and doctors’
offices throughout the United States to treat
various ailments. During the “reefer madness” era

I

III

Vaporizing is the process of heating dried marijuana to a
temperature just below its combustion point of 392°F.
Vaporizers, devices used to use marijuana this way,
consist of a heating source and a delivery system.
II
Tetrahydrocannabinol (THC) is the primary
psychoactive component in marijuana which binds to the
cannabinoid receptors primarily in the brain.

Cannabidiol (CBD) is a marijuana compound that has
medical benefits but is not psychoactive. CBD is one of
approximately 113 cannabinoids identified in cannabis.
IV
Terpenes are a diverse class of hydrocarbons that are
responsible for the aroma of the marijuana plant.

3

 of the 1930s, there was a concerted effort to
convince the country that marijuana posed such a
danger to society, only prohibition could save it,
and the risks continued to be exaggerated for many
years through propaganda.3

was announced that opioid use will be added as a
qualifying condition to ensure that providers have
as many options as possible to treat patients.
Other program enhancements include extending
the variety of medical marijuana products,
improving the dispensing facility experience, and
streamlining program requirements. The State’s
Medical Marijuana Program is a national model,
with almost 1,700 registered providers and 59,653
certified patients.

In 1999 the Institute of Medicine (IOM) found a
base of evidence to support the benefits of
marijuana for medical purposes.4 There is a growing
body of evidence that marijuana has health
benefits. Peer-reviewed literature, news reports,
and anecdotal evidence demonstrate that
marijuana is beneficial for the treatment of pain,
epilepsy, nausea, and other health conditions.
Twenty-nine states and Washington, DC, have
established medical marijuana programs that
benefit patients with numerous conditions. Success
with medical programs across the country has led
some jurisdictions to legalize marijuana for
regulated adult use5 (eight states and Washington,
DC). Low THC/high CBDV products are approved in
17 additional states (See Appendix A Figure 1).6

In addition to health impacts, the prohibition of
marijuana has had significant impacts on criminal
justice. The Marijuana Reform Act of 1977
decriminalized private possession of a small amount
of marijuana, punishable by a maximum fine of
$100. However, possession of marijuana in public
view remains a misdemeanor. Over the past 20
years, there have been more than 800,000 arrests
for marijuana possession, and the increasing
emphasis on minor marijuana arrests has had a
disproportionate impact on communities of
color.7 The over-prosecution of marijuana has had
significant negative economic, health, and safety
impacts that have disproportionately affected lowincome communities of color. In 2012, the
Governor introduced legislation to ensure that
possession of a small amount of marijuana, whether
public or private, is treated as a violation and not as
a misdemeanor. The legislature failed to adopt the
proposal. Because of the over-prosecution of
marijuana, a regulated program in NYS should
include provisions to address the collateral
consequences of prior criminal convictions for
marijuana possession or use, such as barriers to
housing and education. As the Governor has stated,
the impact of legalization in surrounding states has
accelerated the need for NYS to address
legalization. It has become less a question of
whether to legalize but how to do so responsibly.

In addition, studies have found notable associations
of reductions in opioid prescribing and opioid
deaths with the availability of marijuana products.
States with medical marijuana programs have been
found to have lower rates of opioid overdose
deaths than other states.
In 2014, Governor Cuomo signed the
Compassionate Care Act into law, establishing New
York State’s Medical Marijuana Program. Since the
program was established, continued improvements
have been made to better serve patients. To
improve patient access, nurse practitioners and
physician assistants were approved to certify
patients for medical marijuana, and the number of
organizations approved to manufacture and
dispense medical marijuana was increased. In
addition, the list of qualifying conditions was
expanded to include chronic pain and posttraumatic stress disorder. Most recently, in
response to the unprecedented opioid epidemic, it

A regulated marijuana program would have health
social justice and economic benefits. However, risks

V

Low THC/high CBD products do not have psychoactive
components and are used for medicinal purposes
through oral ingestion or topical application. These

products can be legal in states that do not have a medical
marijuana program.

4

 Findings

associated with marijuana have been identified,
although research for some of those risks is divided.
For example, research has demonstrated an
association between maternal marijuana smoking
and lower birth weight of newborns. Marijuana use
may be harmful to the lungs if a combustible form is
smoked. For individuals who are susceptible to
psychosis, regular use lowers age of onset of
psychosis.8 In addition, there are valid concerns
about traffic safety. Risks can be monitored and
reduced in a regulated marijuana environment with
the establishment of regulations that enhance State
control. Regulating marijuana enables public health
officials to minimize the potential risks of marijuana
use through outreach, education, quantity limits at
point of sale, quality control, and consumer
protection.

I. Health
Regulating marijuana reduces risks and
improves quality control and consumer
protection.
The organization Doctors for Cannabis Regulation
states that regulation benefits public health by
enabling government oversight of the production,
testing, labeling, distribution, and sale of
marijuana.9 Potency can vary widely based on the
strain of marijuana, the way the plant is grown, the
part of the plant that is used, how it is stored, and
how it is consumed.10 Consumers purchasing
marijuana on the unregulated market are at a
severe disadvantage for understanding the nature
(e.g., potency and safety) of the product they are
acquiring. In an unregulated market where there is
no standardization or quality control, there are
many opportunities for unsafe contaminants to be
introduced, such as fungi spores, mold, bacteria,
heavy metals, pesticides, and growth enhancers. As
such, regulated marijuana introduces an
opportunity to reduce harm for consumers through
the requirement of laboratory testing and product
labeling.11 Similar protections are in place for the
alcohol and tobacco industries. In a regulated
environment, individuals know what they are
consuming and can choose a product accordingly.
Trained employees can provide guidance and
education at point of sale.

The positive effects of regulating an adult (21 and
over) marijuana market in NYS outweigh the
potential negative impacts. Harm reduction
principles can and should be incorporated into a
regulated marijuana program to help ensure
consumer and industry safety. Legalizing
marijuana could remove research restrictions in
NYS, which will enable the State to add to the
knowledge of both the benefits and risks. In
addition, NYS would be one of the largest
regulated marijuana markets. As such, there is
potential for substantial tax revenue in NYS, which
can be used to help support program initiatives in
areas such as public health, education,
transportation, research, law enforcement and
workforce development. Tax revenues can also
support health care and employment. Finally,
legalization of marijuana will address an important
social justice issue by reducing disproportionate
criminalization and incarceration of certain racial
and ethnic minority communities.

➢ Subject matter experts noted that a regulated
environment will support consumer choice of
content, because education about THC and CBD
levels can be made available. Consumers can be
given information about the experience they can
expect based on the product they purchase and
the method of ingestion. Comparisons were made
to New York’s Medical Marijuana Program, in
which pharmacists and patient counseling are
available in dispensaries. People are advised to
‘start low and go slow’ and find the right fit for
them.

5

 reductions in opioid deaths and opioid prescribing
with the availability of marijuana products. States
with medical marijuana programs have been found
to have lower rates of opioid overdose deaths than
other states,18 perhaps lower by as much as 25
percent.19 Studies on opioid prescribing in some
states with medical marijuana laws have noted a
5.88 percent lower rate of opioid prescribing, and
the implementation of adult-use marijuana laws
(which all occurred in states with existing medical
marijuana laws) was associated with a 6.38 percent
lower rate of opioid prescribing.20 Following
legalization of adult-use marijuana in Colorado, the
State saw a short-term reversal of the upward trend
in opioid-related deaths.21

Research in Colorado found after medical marijuana
legalization, there was a significant increase in the
number of children under age 12 admitted to
emergency rooms due to unintentional marijuana
ingestion (over half the cases involved medical
marijuana “edibles”).12
A regulated marijuana program should create
guidelines to ensure packaging is not attractive to
children. Packaging should be child proof and
opaque and contain a visible warning label to avoid
accidental ingestion and deter minors from using
the products. Testing and labeling products will
ensure quality and protect public health. A harm
reduction approach will ensure consumers are
informed about their choices and understand the
chemical make-up and potency of the products they
purchase.

A regulated marijuana program should promote
awareness of marijuana as an effective pain
treatment and an alternative to opioids. A
regulated marijuana program should coordinate
with the State’s Medical Marijuana Program and
provide education on the assistance that is available
through the Medical Marijuana Program.

Marijuana may reduce opioid deaths and
opioid prescribing.
Research indicates that regulating marijuana can
reduce opioid use (legal and illegal). Medical
marijuana has added another option for pain relief
which may reduce initial prescribing of opioids and
assist individuals who currently use opioids to
reduce or stop use. Legalization may ease access to
marijuana for pain management. The opioid
epidemic in NYS is an unprecedented crisis.13
Diagnoses of opioid use disorder are on the rise.14
Besides the dramatic increase in the number of
deaths in the past few years, this epidemic has
devastated the lives of those with opioid use
disorder, along with their families and friends.
Those with opioid use disorder are at higher risk for
HIV, Hepatitis C, and chronic diseases.15

Marijuana has intrinsic health benefits and
risks.
Evidence supports the efficacy of marijuana’s
therapeutic benefits. Growing research has
demonstrated that marijuana is beneficial for the
treatment of pain, epilepsy, nausea, and other
health conditions. The medicinal benefits of
marijuana have been acknowledged.22 The negative
health consequences of marijuana have been found
to be lower than those associated with alcohol,
tobacco and illicit drugs including heroin and
cocaine.23,24
There is an association between marijuana use and
impairment in the cognitive domains of learning,
memory, and attention (due to acute marijuana
use).25, 26

In NYS, overdose deaths involving opioids increased
by about 180 percent from 2010 (over 1,000
deaths) to 2016 (over 3,000 deaths).16 Opioid
overdose is now commonplace throughout NYS.
Marijuana is an effective treatment for pain, greatly
reduces the chance of dependence, and eliminates
the risk of fatal overdose compared to most opioidbased medications.17 Studies of some states with
medical marijuana programs and/or regulated
adult-use have found notable associations of

Amotivational syndrome is anecdotally reported to
be associated with chronic marijuana use. This is
not supported in the literature. One study found
that while cannabis was associated with a transient
amotivational state, dependence was not
associated with amotivation.27 Another study, using

6

 a survey to compare daily users to never-users
found no difference in motivation as measured by
an Apathy Scale.28

There is strong evidence that individuals with
serious mental illnesses (SMI) in general, including
psychotic disorders, bipolar disorders, and serious
depression, use marijuana at high rates, and those
who continue using marijuana have worse
outcomes and functioning.34

Marijuana may be harmful to the lungs if a
combustible form is smoked. However, alternatives
can be used (e.g., vaping, edibles). Regulating
marijuana will provide an opportunity to furnish
information regarding the various methods of
consumption.

Adolescents who use marijuana regularly have an
increased risk of developing psychosis.35
Additionally, for individuals who are susceptible to
psychosis, regular use of marijuana lowers the age
of onset of psychotic disorders.36 People with
psychotic disorders who use marijuana regularly
have worse symptoms, functioning, and health
outcomes, and stopping marijuana use improves
mental health outcomes.37,38

Most women who use marijuana stop or reduce
their use during pregnancy. 29 There is research that
demonstrates an association between maternal
marijuana smoking and lower birth weight of the
newborn. Data have not identified any long-term or
long-lasting meaningful differences between
children exposed to marijuana in utero and those
not exposed.30 There are insufficient data to
evaluate the effects of marijuana use on infants
during lactation and breastfeeding, and in the
absence of such data, marijuana use is discouraged.
The American College of Obstetrics and Gynecology
(ACOG) recommends that women who are pregnant
should be discouraged from using marijuana due to
concerns regarding impaired neuro-development as
well as maternal and fetal exposure to the adverse
effects of smoking. The ACOG recommends seeking
alternative therapies for which there are better
pregnancy-specific safety data.31

In individuals diagnosed with bipolar disorder, there
is evidence of an association between regular
marijuana use and increased symptoms of mania
and hypomania.39,40
It is important to note that there is some evidence
that CBD can reduce the effect of THC on psychosis,
and using marijuana with lower levels of THC may
be less likely to be associated with the development
of psychosis.41 In addition, research has shown that
genetics and other environmental factors also have
significant effects on the course of SMI.42
➢ Subject matter experts noted that there are many
possible confounding factors when examining the
relationship between marijuana use and various
health outcomes, and we should, therefore, be
careful about stating as fact that one thing causes
another. Others noted there is substantial
evidence of the effects of marijuana use on
persons at risk for psychotic illnesses, and there is
controversy about its effects on people with less
serious mental illnesses such as milder depression
and anxiety.

A regulated marijuana program should furnish
education about the health benefits and risks of
marijuana and provide guidelines to reduce
potential harms of marijuana use.
Marijuana can have effects on mental
health.
There is little evidence that marijuana use is
significantly or causally associated with more
common mental illnesses (such as mild-tomoderate depression or anxiety) or other adverse
outcomes (such as suicide) in the general
population. Regular marijuana use in youth is
associated with lower academic achievement,32 but
causation is unclear (e.g., cognitive vs. motivation
vs. other factors).33

Public health surveillance and education officials
will need to conduct surveillance on youth
marijuana use and any possible impacts on the
onset and incidence of psychosis, as well as effects
on academic achievement. Mental health
professionals will need to monitor the effects of

7

 substance by adolescents.47 Eighty to ninety percent
of American eighteen-year-olds have consistently
reported that marijuana is “very easy” or “fairly
easy” to obtain since the 1970s.48 Research
regarding tobacco demonstrates that establishing a
suitable minimum legal age can have a dramatic
impact on youth access. Research has identified a
variety of mechanisms by which youth obtain
tobacco, one of which is social sources. Friends who
are 18 years of age or over are a major source of
tobacco for older adolescents.49 Data provides a
strong reason to believe that increasing the
minimum legal age to 21 will contribute to
reductions in youth tobacco use. Drawing parallels
from tobacco research, regulating marijuana would
enable the State to establish controls over
marijuana use, including setting legal age limits,
which will reduce youth access to marijuana. In
addition, the creation of a regulated marijuana
program would establish a legal distinction between
underage and adult marijuana use.50

marijuana legalization on the population with SMI,
and resources will need to be directed to
prevention, harm reduction and treatment efforts
for individuals with SMI.
Changes in overall patterns of use are not
likely to be significant.
It is likely that some people who have never used
marijuana before due to fear of legal repercussions
may try marijuana once legal sanctions are lifted.43
Some states that have a regulated marijuana
program have seen a slight increase in adult use,
while other states have seen no increase at all.44
This does not mean that those individuals will
become regular or even semi-regular marijuana
users.45
It is important to note that reported increases in the
number of people who use marijuana can be
partially attributed to under-reporting prior to
legalization, when there is reluctance to report
illegal drug use due to fear of legal repercussions
and stigma. Decreasing social stigma surrounding
marijuana and no longer having to fear legal
repercussions can lead to accurate reporting on use
in surveys after legalization.46

➢ Subject matter experts noted that marijuana will
be more difficult for youth to obtain in a regulated
marijuana environment. They stated it is easier
for teens to get marijuana than alcohol because
alcohol is regulated and marijuana is not. They
asserted that the illicit economy operates now
with no rules or regulations, youth know how to
obtain marijuana, and the notion that regulation
will foster greater demand is unfounded.

➢ Subject matter experts noted that there is no
conclusive evidence about whether legalizing
marijuana increases use. It was pointed out that
as with alcohol, use varies. Subject matter experts
noted that brief increases in use in Colorado and
Washington leveled out. They noted that such
increases are, at least in part, the result of
tourism. People in states without legal access are
willing to travel to states where marijuana is
legal. As more of the country legalizes, these
increases will fade.

Law enforcement raised a concern about a report
from the Rocky Mountain High Intensity Drug
Trafficking Area (RMHIDTA), which tracked the
impact of marijuana legalization in the State of
Colorado and found that youth past-month
marijuana use increased 20 percent in the two-year
average (2013-14) since Colorado legalized
regulated marijuana compared to the two-year
average prior to legalization.

A regulated marijuana program should monitor and
document patterns of use to evaluate the impact of
legalization on use.

However, other studies have shown little or no
change in adolescent marijuana use following
legalization. Data from multiple sources indicate
that legalization in Colorado had no substantive
impact on youth marijuana use.51 Marijuana use
rates, both lifetime use and current use, among

The majority of credible evidence suggests
legalization of marijuana has no or minimal
impact on use by youth.
Criminalization in the U.S. has not curbed teen use.
Marijuana is the most commonly used illicit

8

 high school students in Colorado did not change
significantly following legalization. Similarly, past
30-day use among persons 12-17 years old in
Colorado did not change significantly following
legalization.52 A 2017 study of adolescent marijuana
use before and after regulated marijuana
implementation in Colorado found there was little
change in adolescent marijuana use but a significant
increase in perception of ease of access.53
Moreover, post legalization rates in Colorado were
not significantly different from usage rates
nationally.54

use. Legalization will allow for a more honest and
trustworthy discussion.
An adult-use regulated marijuana program should
prohibit use by youth (individuals under 21). At the
same time, there should be an emphasis on
education that addresses adolescents’ perceptions
of the risks, benefits, social norms, and peer
influences surrounding marijuana and highlights
safety and harm reduction. A regulated marijuana
program should implement strategies to reduce
youth use of marijuana.

Meta-analysis of existing literature does not
support the hypothesis that recent changes to
marijuana laws have led to an increase in marijuana
use prevalence in adolescents.55 According to the
2016 U.S. Substance Abuse and Mental Health
Services Administration National Survey on Drug
Use and Health, rates of marijuana use among the
nation's 12- to 17-year-olds dropped to their lowest
level in more than two decades. According to a
2016 report from the State of Oregon, recent trends
in youth use have been stable during the period
following the enactment of adult-use
regulations.56 A Washington State evaluation report
states that across grades 6, 8, 10, and 12, marijuana
use indicators have been stable or fallen slightly
since legalization. The Monitoring the Future
Survey conducted by the National Institute on Drug
Abuse (NIDA) found that lifetime and current
marijuana use among 8th and 10th graders fell
substantially between 1996 and 2016 and remained
stable among 12th graders nationally.57

Since marijuana is the most commonly used illegal
substance,58 people who have tried other
substances also are likely to have tried marijuana
and alcohol. The majority of individuals who use
marijuana do not try other illicit drugs.59
Additionally, an individual’s environment, genetics
and social context are important in understanding
an individual’s propensity to use substances and
develop a substance use disorder.60 In a study of
initiation into marijuana use which utilized twins to
control for genetic factors, researchers found that
causal conclusions cannot be drawn related to
initiation into marijuana use. This study also found
that early regular use of tobacco and alcohol were
the two factors most consistently associated with
later illicit drug use.61
➢ Subject matter experts stated that the research
community generally does not recognize the
premise that marijuana leads to the use of other
substances as a legitimate or plausible assertion.
Legalizing marijuana results in a
reduction in the use of synthetic
cannabinoids/novel psychoactive
substances.

➢ Subject matter experts stated there are concerns
about the effects of marijuana use on the
developing brain. They also noted that there is no
convincing evidence about whether legalizing
marijuana increases use, and increasing use
among youth has not been observed. There is
more open discussion now, and the perception is
that marijuana is less dangerous. Subject matter
experts note that the perception is that the
credibility of authority figures is weak because
historically, young people have received improper
messaging about the dangers of marijuana

The Global Drug Survey indicated that countries
that decriminalize marijuana have lower
prevalence rates of synthetic marijuana use.62
Synthetic cannabinoids are compounds that are
sprayed on plant material and purchased for
smoking as a “legal high.” THC is a partial agonist
at the cannabinoid receptor, while these

9

 compounds are full agonists and more potent.
Therefore, while the effects are often somewhat
like marijuana, the adverse effects can be far
more severe, including delirium, lethargy and
coma, seizures and hallucinations.63 Other
compounds may also be in the mix. For example,
in April, there were deaths from these products.64
There is disagreement between some experts
about the effect legalization will have on synthetic
cannabinoid use. However, it is clear that it is
often chosen to avoid detection in urine testing.65
One survey found that most users prefer natural
cannabis.66 The synthetic cannabinoid market
should be eliminated. A reduction in synthetic
cannabinoid availability and use would have
particular benefits for individuals with SMI.

treat Cannabis Use Disorder, and marijuana
legalization across the country has led to more
dialogue and research around the efficacy and
availability of such treatment.71
It is important to ensure that experts in the field of
substance use disorder do not conflate the
treatment of Cannabis Use Disorder with other
substance use disorders. Every effort should be
made in a regulated marijuana program to avoid
tobacco and alcohol industry participation.
Cannabinoid Hyperemesis Syndrome can also occur
due to heavy use of marijuana and presents with
episodes of severe nausea and cyclical vomiting.
Symptoms dissipate when marijuana use is stopped.
More research is required to better understand why
marijuana has antiemetic properties, yet it can elicit
this response.72 An analysis of the medical records
of 1,571 patients with the characteristic cyclical
vomiting of the syndrome indicated that
approximately 98 (6 percent) had Cannabinoid
Hyperemesis. Further research is needed to truly
identify prevalence of the syndrome.73

A regulated marijuana program should include
among its goals reducing the use of synthetic
cannabinoids/novel psychoactive substances and
ultimately eliminating the synthetic cannabinoid
market.
Problematic marijuana use includes
Cannabis Use Disorder and Cannabinoid
Hyperemesis Syndrome.
There is a lack of consensus as to what percentage
of individuals who use marijuana develop some
form of dependence, but estimates range from 8.9
percent to 30 percent of the population who uses
marijuana. 67,68 The risk factors for a poor outcome
are unclear. However, it will be important to ensure
access to treatment, support and care when
necessary.

➢ Subject matter experts noted that a framework of
regulation could support a more appropriate level
of treatment for marijuana use that focuses on
harm reduction. Legalization could result in more
effective partnerships in communities throughout
the State. Subject matter experts in substance use
services provided data on marijuana treatment
admissions from two states that have legalized
marijuana. According to the Colorado
Department of Human Services, Office of
Behavioral Health, marijuana treatment
admission rates in Colorado increased each year
between 2011 and 2015 but declined significantly
during 2016. According to the Washington State
Department of Social and Health Services, Division
of Behavioral Health and Recovery, marijuana
treatment admissions in Washington State
declined each year between 2012 and 2015.

The Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), includes criteria to
diagnose Cannabis Use Disorder. Cannabis Use
Disorder is problematic marijuana use that impedes
an individual’s quality of life and tolerance to
marijuana, and use of marijuana continues despite
awareness of physical or psychological problems
attributed to use.69 Estimates of Cannabis Use
Disorder prevalence vary from 2.5 percent to 6.3
percent, and most cases are not treated.70 Data
indicates that Cannabis Use Disorder is more
common among people diagnosed with and treated
for mental illnesses. Psychotherapy can be used to

The expertise of substance use specialists will be
critical in addressing the issues associated with
problematic marijuana use, and resources must be
directed to treatment, support and care when

10

 needed. The identification of persons who might
need assistance with their marijuana consumption
and referral to treatment centers or other
supportive services should be a component of a
regulated marijuana program. In addition,
education and labeling would allow individuals to
self-select lower potency items/products with
higher CBD/lower THC. Education and labeling
should be used to support consumer choice and
reduce harm.

A regulated marijuana program must provide
education on the assistance that is available in the
Medical Marijuana Program to ensure populations
that need medical guidance and support have the
information necessary to access the program.
Growing the medical program while implementing a
regulated marijuana program will reduce the risks
of legalizing marijuana for individuals who require
medical guidance.

The NYS Medical Marijuana Program would
adapt to coordinate with a regulated
marijuana market.
New York State’s Medical Marijuana Program has
almost 1,700 registered providers and serves 59,653
certified patients. In the two years since the
Medical Marijuana Program was implemented,
there have been 27 reported adverse events out of
about 300,000 transactions. None resulted in death,
and most persons changed to another product
without further incident.

II. Criminal Justice and
Public Safety
Criminalization of marijuana has not curbed
marijuana use despite the commitment of
significant law enforcement resources.
Marijuana use has remained relatively stable
nationally since 2002, with minor changes.

As part of the planning for the potential regulation
of marijuana, it will be important to re-examine the
State’s Medical Marijuana Program to ensure access
for anyone in need and determine the changes
necessary to ensure both programs address their
defined objectives. In addition, the State will
evaluate information from the eight states (and
Washington, D.C.) that currently operate both
medical and recreational marijuana programs to
determine how they assure patient safety.
Individuals who could benefit from medical
marijuana should work with a provider to
determine if they should utilize the Medical
Marijuana Program.

Criminal records impede New Yorkers’
lives.
Statewide, New York’s marijuana arrest rate of 535
arrests per 100,000 people was the highest of any
state in 2010 and double the national average. That
year, there were 103,698 marijuana-possession
arrests in NYS – 29,000 more than Texas, the state
with the next highest total.75 The impact of low
level marijuana offenses extends beyond utilization
of law enforcement and criminal justice resources.
Individuals who have a criminal record often face
challenges throughout their lives accessing gainful
employment and qualifying for federal housing.76
Marijuana-related convictions have a lasting impact
on the lives of individuals and their families.

➢ Subject matter experts noted that regulated
marijuana program participants who would benefit
from medical advice and support can be transitioned
to the Medical Marijuana Program. A 2018 study of
health conditions and motivations for marijuana use
among young adult medical marijuana patients and
non-patient marijuana users in Los Angeles found that
a notable proportion of non-patients reported health
problems that might qualify them for the medical
marijuana program.74

Marijuana prohibition results in
disproportionate criminalization of certain
racial and ethnic groups.
Across the country, individuals who are Black are
nearly four times more likely than individuals who
are White to be arrested for marijuana possession,
despite data showing equal use among racial

11

 groups.77 Stop and Frisk data from NYC presented in
a 2013 report from the NYS Office of the Attorney
General demonstrated that there were racial
disparities in case outcomes among those stopped
and arrested. Individuals who are White who were
identified by Stop and Frisk were almost 50 percent
more likely than individuals who are Black to have
an arrest end in an Adjournment in Contemplation
of Dismissal, meaning they avoided a conviction.78
While marijuana arrests have dropped significantly
in New York City since 2014, NYS Division of
Criminal Justice Services data demonstrate that 86
percent of the people arrested for marijuana
possession in the fifth degreeVI in 2017 were people
of color; 48 percent were Black, and 38 percent
were Hispanic. Only nine percent were White.79

were arrested at five times the rate of individuals
who are White.

Incarceration has a negative impact
on families and communities.
Arrests and incarceration negatively impact the
health of communities and individuals by
destabilizing families, hindering access to education
and health care, lowering employment
opportunities, increasing poverty, and limiting
access to housing, particularly in low-income
communities of color where arrests are
concentrated despite equivalent rates of marijuana
use across racial groups. Incarceration of family
members destabilizes families and is considered an
adverse childhood experience (ACE)VII, which is
associated with decreased health-related quality of
life (HRQOL) into adulthood.80 Research indicates
that incarceration also has an impact on community
health in many areas (including teenage
pregnancies and sexually transmitted infections).81

➢ Subject matter experts noted one of the biggest
drivers of racial disparities in criminalization and
incarceration rates is marijuana, and the best way
to address it is to legalize marijuana. A great
majority of arrests are for violations or
misdemeanors that most people no longer view as
criminal behavior. It is rare that these arrests lead
to the discovery of guns or violent crimes. Subject
matter experts also noted that continued
prohibition of public consumption will reduce the
impact of regulated marijuana on arrests. They
highlighted a recent media report that described
an analysis of NYC police data which found that
while marijuana-related arrests have dropped,
across NYC, individuals who are Black were
arrested on low-level marijuana charges at eight
times the rate of White, non-Hispanic people over
the past three years. Individuals who are Hispanic

➢ Subject matter experts emphasized the need to
address the economy of the unregulated market.
Regulating marijuana would provide an
opportunity to direct resources to workforce
development and job creation. Subject matter
experts representing law enforcement said that
rather than spending time on marijuana arrests,
police could devote more time to other aspects of
their work, such as community policing and
building trust.

VI

VII

Persons are guilty of criminal possession of marijuana
in the fifth degree when they knowingly and unlawfully
possess: 1. marijuana in a public place and such
marijuana is burning or open to public view; or 2. one or
more preparations, compounds, mixtures or substances
containing marijuana and the preparations, compounds,
mixtures or substances are of an aggregate weight of
more than twenty-five grams. Criminal possession of
marijuana in the fifth degree is a class B misdemeanor.
(New York Penal Law §221.10)

Adverse childhood experiences (ACEs), according to
the Substance Abuse and Mental Health Services
Administration (SAMHSA), are stressful or traumatic
events, including abuse and neglect. They may also
include household dysfunction such as witnessing
domestic violence or growing up with family members
who have substance use disorders. ACEs are strongly
related to the development and prevalence of a wide
range of health problems throughout a person’s lifespan,
including those associated with substance misuse.

12

 Resources should be directed to community
reinvestment in health care, education and
workforce development.

crime, and the conduct took place in their own
home.84
Conclusions cannot be drawn from the
existing research on the impact of
marijuana use on motor vehicle traffic
crashes (MVTC).
A primary concern of law enforcement is the
possibility of increased impaired driving and car
crashes in a regulated marijuana environment. In
the last 40 years, law enforcement has made great
strides in making highways safe. According to law
enforcement representatives, in 1973, 35 percent of
motorists who were stopped had alcohol in their
blood, and 7.5 percent exceeded the legal
limit. Today, only eight percent of motorists who
are stopped have alcohol in their blood, and only
1.5 percent exceed the legal limit.

There has been no increase in violent crime
or property crime rates around medical
marijuana dispensaries.VIII,82
Concerns exist around the possibility that there
could be an increase in crime, specifically robberies
and burglaries, because sale of marijuana is a cash
business. However, a representative of the State’s
Medical Marijuana Program, which is a cash-only
business, stated that there have been no robberies
or adverse impact in communities where
dispensaries are located.
➢ Subject matter experts emphasized the possibility
of a reduction in violent crime due to the
substantial reduction in the unregulated market,
which would lead to a decline in home invasions
associated with illegal marijuana and the
associated violence. Law enforcement subject
matter experts noted that inhabitants of homes
involved in the unregulated market install
barricades and traps, which present a danger to
law enforcement. In addition, some marijuana is
still sold by gangs, and that business model is
toxic to neighborhoods.

➢ Subject matter experts corroborated the concern
that marijuana can lead to impairment and
discussed the effective anti-DWI efforts that can
be expanded to include education about driving
while under the influence of marijuana. Law
enforcement has changed the cultural dialog on
drinking and driving, and their expertise will be
critical in effectively addressing the issues of
driving while impaired from marijuana. There was
consensus that resources must be made available
to support education and address law
enforcement budgetary needs with the
establishment of a regulated marijuana program.

A regulated marijuana program should monitor
crime rates around dispensaries and address
instances that may arise.
Marijuana possession is the fourth most
common cause of deportation nationally.83
Federal law holds jurisdiction over the possession of
marijuana for immigrants, even in states that have
legalized. Furthermore, a non-citizen who admits to
an immigration official that they possess marijuana
can be denied entry into the United States, or their
application for lawful status or naturalization may
be denied. Depending on the circumstances, it can
make a lawful permanent resident deportable. This
is true even if the conduct was permitted under
state law, the person never was convicted of a

Research indicates that marijuana use by drivers is
associated with impaired judgment, motor
coordination and reaction time.85 A meta-analysis
suggests that marijuana use by drivers is associated
with an increased risk of involvement in motor
vehicle crashes.86 However, three years after the
legalization of regulated marijuana in Colorado,
motor vehicle crash rates overall were not
statistically different, although this evidence is still
preliminary.87

VIII

able to advise customers on the strain or type of
marijuana best suited for their needs.

Dispensaries are stores from which marijuana is sold
to consumers. Individuals who work at these stores are

13

 Few states collected pre-legalization baseline data
to use as a comparator for evaluation purposes.
States that have regulated marijuana have an
inability to conclusively state the role that
marijuana has played in traffic safety. Data from
the National Highway Transportation
Administration's Fatality Analysis Reporting System
on crashes contain the caveats that they cannot be
reliably compared across or within jurisdictions or
across years.88

organizations refute the fact that THC in the
bloodstream detects impairment.

There are challenges in
measuring impairment from the
effects of marijuana.
Challenges exist with drug testing
methodology and analysis, including risk
of inaccuracy (false positives and false
negatives), specimen contamination that
may occur along the chain of custody,
and issues with storage.

The number of drivers using marijuana has been
increasing. The National Roadside Survey conducted
at 60 sites around the country found that THC was
by far the most prevalent drug detected in their
sample of drivers. In 2007, 8.6 percent of drivers
tested positive for THC. This increased to 12.6
percent in 2013-14, representing a 48 percent
increase in the prevalence of drivers testing positive
for THC. Fortunately, the percentage of drivers
testing positive for alcohol declined from 12.4
percent in 2007 to 8.3 percent.89 There is no further
funding for these studies, and they cannot be used
to produce state-specific data.
Studies of the contribution of marijuana to MVTC
have had varied results. Two meta-analyses
reported near doubling of the risk of fatal crash
regardless of the presence of alcohol or other
drugs.90,91 Another study examining similar data
found a non-significant contribution of marijuana to
crash risk when the model also accounted for the
presence of other drugs.92 Unfortunately, available
data is flawed by inconsistencies in both collection
and analyses of body fluid samples and descriptions
of demographics and crash types.93

In testing for impairment by alcohol, there is a
strong correlation between breath/blood levels and
impairment, allowing for laws to be set according to
these measurements. Testing for marijuana use is
more complicated. There is currently no
breathalyzer for roadside testing for marijuana
use.IX Urine testing can only detect an inactive
metabolite which may be present for days or weeks
after use. Blood levels are more accurate. However,
this is an invasive test requiring several legal steps.
The THC levels drop in the time it takes to go from
the roadside to the blood draw. Furthermore, there
is no clear correlation between the level of THC in
the blood and impairment. Due to the lipidsolubility of THC, a frequent marijuana user may
have measurable THC in their blood, even if they
have not used in several days and are not
necessarily impaired.96 The Joint Guidance
Statement of the American Association of
Occupational Health Nurses and the American
College of Occupational and Environmental
Medicine97 reviewed the evidence and suggested
that a limit of 5 ng/mL of THC measured in serum or
plasma would allow employers to identify
potentially impaired employees yet also notes a
medical examination focused on identifying
impairment is always recommended.

There are questions about whether presence of THC
in an individual’s blood stream is an indicator of
impairment. The National Highway Traffic Safety
Administration94 and the AAA Foundation for Traffic
Safety95 have both made the distinction that unlike
alcohol, presence of THC in an individual’s blood
stream does not equate to impairment. Peerreviewed literature and major national

Data on the impact of legalization in states that
have passed laws is useful, but it must be noted

IX

A product is under development albeit the timeline is
unknown.

14

 that not all drivers arrested or in fatal crashes are
tested for alcohol and/or drugs. The selection bias
may lead to over- or under-estimating the impact.

driving while intoxicated were the result of
marijuana-impaired driving vs. 21.4 percent after
legalization.99 They noted that in the last 40 years,
law enforcement has worked to remove intoxicated
drivers from our roadways and has made great
strides in making highways safe. They are
concerned that legalizing marijuana will increase
impaired driving and car crashes, and there could
be loss of progress.

A study comparing motor vehicle-related fatalities
in Washington and Colorado to eight similar states
found that three years after marijuana legalization,
changes in motor vehicle fatality rates were not
statistically different from those in similar states
without regulated marijuana.

➢ Subject matter experts noted that the dangers of
driving under the influence of alcohol are worse
than the dangers of driving under the influence of
marijuana. However, there have been mixed
reports regarding the impact of regulated use on
the increase of traffic accidents and fatalities.

Medical marijuana has been increasing in
availability since 1996 when California passed the
first law. The number of California drivers killed in
crashes that tested positive for drug involvement
decreased nine percentage points, from the 20092013 average of 28 percent to 19 percent in 2015
(THC is not broken out).98

There will be a budget and workload impact on law
enforcement related to determining impairment.
Currently, Drug Recognition Experts (DREs) are used
to measure roadside impairment. DREs are certified
law enforcement officers with experience in
DUIIX/drug enforcement who go through extensive
training and a certification process. The evaluation
the DRE uses to measure impairment is
standardized and considers the subject’s mental
and physical condition to determine if their
impairment is due to drug use (or perhaps an
underlying medical condition).100 This method of
measuring impairment is resource intensive, and
there are few of them. There will be substantial
expense associated with increasing the number of
DREs. DREs are trained outside of NYS at the
expense of NYS law enforcement. While a
breathalyzer for THC may be in development, there
is currently no technology for determining
impairment. Law enforcement expressed concern
about launching a legal program hoping that
technology will catch up. They noted that
developing and validating a screening tool for
purposes of establishing an enforcement paradigm
is a lengthy and expensive process involving legal
challenges, court rulings, and judicial notice.

While existing information suggests a lower impact
than might have been expected, legalization of
adult use of marijuana raises valid concerns about
traffic safety.
Representatives of law enforcement provided a
December 2017 study conducted by the State
University of New York, Rockefeller College of Public
Affairs and Policy, Institute for Traffic Safety
Management and Research, on drug involvement in
fatal and personal injury (F&PI) crashes on NYS
roadways from 2012 to 2016. The analysis found
that although less than one percent of all F&PI
crashes each year were drug related, the number of
drug-related F&PI crashes increased 20 percent
over the five years from 2012 to 2016, and 26
percent of all fatalities in 2016 were drug related,
up from 18 percent in 2012-2014. While the study
examined the extent to which crashes on New York
State’s roadways involve drugs, it did not examine
the extent to which drug-related crashes involved
marijuana use.
Representatives of law enforcement indicated that
in Washington State, six months prior to the
legalization of marijuana, 14.6 percent of arrests for
X

Driving under the influence of intoxicants (DUII) can
also be referred to as Driving While Intoxicated (DWI).

15

 Advanced Roadside Impaired Driving Enforcement
(ARIDE) training is provided to law enforcement
personnel as a pre-requisite to DRE training. ARIDE
training may be needed for all law enforcement
personnel should the decision be made to legalize
marijuana use.

•

Law enforcement raised a concern about drug
detection canine units trained to find marijuana.
The legalization of marijuana will result in the loss
of these dogs, whose training involved significant
time and expense. Other states have faced the
same situation and have re-assigned their canine
units.

•

•

•
•
•
•

There will be budgetary implications for law
enforcement associated with training personnel
(e.g., ARIDE training), training and certification of a
significant number of personnel as DREs, and the
impact on canine programs.

Employing a robust monitoring and oversight
system with the ability to issue fines for
violations and revoke licenses as needed;
Promoting further study of methods of
detecting impaired driving and the impact of
legalization of marijuana on the safety of the
State’s roadways;
Enhancing the State’s successful anti-DWI
efforts to include impaired driving;
Educating the public as to the potential risks of
excessive use;
Imposing fines for providing false identification;
Determining hours of operation restrictions for
retail establishments; and
Imposing a tracking, reporting and compliance
system for the regulated marijuana program.

III. Economic Estimates

➢ Subject matter experts urged State
representatives not to view the difficulties in
measuring impairment as a barrier to legalization
when solutions can be found. They suggested
that mechanisms should be sought to reduce the
cost of DRE training and improve access, such as
conducting training in NYS. Also noted was that
most drugged driving is due to the use of opioids
and prescription drugs.

The marijuana industry is expanding.
As more states develop a regulated marijuana
market, the industry is growing substantially,
more licenses are issued for dispensaries, and
more consumers exit from the unregulated
market. Regulating marijuana will create jobs.
Industry sources estimate that there are
between 165,000 to 230,000 full- and parttime workers in the United States marijuana
industry.101

While existing information suggests a lower impact
than might have been expected, legalization of
adult use of marijuana raises valid concerns about
traffic safety. Efforts are in place to expand the
monitoring of this risk in NYS. An expansion of
education to the public, along with the
development of laws and procedures, can assist in
reducing the negative impacts.

Marijuana regulation could generate longterm cost savings.
Legalizing marijuana is anticipated to lead to a
reduction in costs associated with illegal marijuana,
including police time, court costs, prison costs and
administrative fees.102 There will be costs associated
with the implementation of a regulated marijuana
program; however, the revenue generated is likely
to sustain the program after the first year.

In conclusion, it will be essential to ensure public
safety and the integrity of the program by, among
other things:
• Enforcing the under-21 purchasing ban;
• Reducing the illegal market and preventing
diversion;
• Ensuring adequate security at cultivation and
dispensing facilities;

Regulated marijuana generates tax
revenue.
For purposes of this impact assessment, the
following analysis of potential tax revenues was

16

 Consumers
The US Census Bureau estimates that the State’s
population in 2017 was 19.85 million, of which 14.9
million (74.9 percent) are aged 21 or older.103 Using
NYS-specific data on marijuana use as reported in
the 2016 National Survey on Drug Use and
Health,104 the proportion of NYS residents who are
marijuana users is estimated to be 8.5 percent,
resulting in an estimate of approximately 1.27
million NYS residents who are marijuana
consumers.

conducted by the DOH and the Department of
Taxation and Finance and reviewed by subject
matter experts in economic evaluations. It is
important to note, however, that the analyses
presented here are for illustration purposes, and
policymakers may want to consider other
approaches.
Estimates of the size of the current illegal market
for marijuana in NYS range from $1.74 billion to
$3.5 billion annually, including sales to NYS
residents and tourists. These amounts and the
inputs used to derive them provide the basis on
which to estimate the potential tax revenues the
State may realize from taxing regulated marijuana
sales. The methodology incorporates certain
economic parameters that illustrate some of the
demand- and price-related uncertainties that may
be encountered given the presence of the current
unregulated market as well as decriminalization and
other factors. This analysis is limited to potential
State and local tax revenues and does not consider
any licensing fees or registration fees that may be
imposed on retail sellers.

In addition, tourists and other visitors to the State
may purchase marijuana after regulated use is
legalized. According to the American Hotel and
Lodging Association, there are over 234,000 hotel
rooms in the State.105 Assuming 80 percent
occupancy with 1.5 adults per occupied room yields
almost 281,000 visitors and other overnight
travelers to the State. It is assumed that half of
these visitors are international travelers and half
are domestic, though it is assumed that 75 percent
of the latter are from outside NYS.106 Further, the
proportion of domestic marijuana users is assumed
to be the same as the national average (7.6
percent), but a lower proportion (6.7 percent) is
applied to derive the number of international users.
As a result, it is estimated that there are an
additional 20,000 marijuana consumers.

Methodology
The potential size of the NYS marijuana market was
projected by combining estimates of the State’s
adult residents (age 21 or older) and visitors that
use marijuana, the average amount they use
annually, and recently reported market prices.
Other factors that might affect the estimated price
and demand for legal marijuana, including
consumers’ behavior in the presence of the current
illegal market and behavioral changes that could
unfold over time as individuals become accustomed
to a regulated marijuana marketplace, are also
considered. The following estimates of the number
of consumers, their marijuana use, and the current
reported price are used as the basis for this
approach to estimate potential revenues for NYS.

Given that marijuana has been legalized in
neighboring states such as Massachusetts and
Vermont and is under consideration in New Jersey,
this analysis did not include any additional
consumers to the calculation of the market.
In total, it is estimated that 1,290,000 consumers
would access the legal market the first year after
legalization of marijuana.XI
Consumption
Fiscal analysis conducted by Washington and
Colorado estimates that the average marijuana user
consumes five ounces of marijuana per year, while

XI

It is possible that persons may come from other states
to NYS to purchase legal marijuana, but that additional
demand is not estimated.

17

 the Department of Taxation and Finance used data
from the National Survey on Drug Use and Health to
estimate that the average marijuana user consumes
almost 7.9 ounces of marijuana per year. Both
estimates are used in this analysis as a high and low
estimate.

Price elasticityXII: RAND researchers assume a price
elasticity of marijuana consumption or demand of
between -0.4 and -1.2, with a point estimate of
-0.54.108 For this analysis, a value of -0.8 was used,
which was the midpoint of the range cited by the
RAND researchers and others.109

Price
The average retail price of marijuana in NYS has
been reported as $270 per ounce for medium
quality strains and $340 per ounce for high quality
strains.107 For this analysis, to derive potential
ranges of tax revenues, $270 per ounce was used as
a low end of the illegal market price range and $340
as the high end of the illegal market price range.

Non-price effect: RAND researchers note that nonprice effects on demand, which arise from reduced
risk of arrest, reduced social stigma, lower risk of
contaminants or mislabeling, and greater product
variety and marketing, can range from 5 percent to
50 percent.110 Five percent was used in these
calculations.
Tax rate: The higher the tax rate imposed, the
higher the legal market price will be. In turn, a
higher legal market price will have a greater price
effect, which will result in users less likely to exit the
unregulated market. The Tax Foundation
recommends that the tax rate not be so high as to
prevent elimination of the illegal market.111 As of
August 2017, marijuana tax rates range from 3.75
percent in Massachusetts to 37 percent in
Washington State of the retail price.112 For
purposes of this analysis, ranges of potential
revenues are presented assuming: 1) imposing the 7
percent retail tax rate currently assessed on medical
marijuana as well as a 15 percent marijuana tax
rate, and 2) a combined State and local sales tax
rate of 8.5 percent for sales outside the
Metropolitan Commuter Transportation District
(MCTD) and 8.875 percent for sales inside the
MCTD. Given these adjustments and the baseline
prices and consumption figures that were
determined, the chart below summarizes the inputs
used to derive the ranges of the first year’s
potential tax revenues (see Table 1 below).

Market Size
Based on inputs and assumptions, purchases of
illegal marijuana in NYS are estimated to be about
6.5 to 10.2 million ounces annually. At an average
retail price of $270 per ounce, the market for
marijuana is estimated to be approximately $1.7
billion; at $340 per ounce, the market is estimated
to be approximately $3.5 billion.
Potential State Tax Revenues
To estimate potential tax revenues, a methodology
used by the State Department of Taxation and
Finance was followed using $270 and $340 prices
per ounce. Moreover, noting that usage can change
and has changed over time, for low-estimate
scenarios, an annual average consumption of 5
ounces per user was used, while 7.9 ounces was
used for high-estimate scenarios. As previously
noted, this analysis makes certain adjustments to
account for changes in demand, including the effect
of the illegal market and other non-price effects.
These adjustments include:
Legal Market Price: This is the price that the product
sells for at retail to the consumer. This price
includes production costs and applicable taxes. For
this analysis, an increase of 10 percent is used in
these calculations.

XII

Price elasticity is a measure of the responsiveness of
quantity demanded to a change in price.

18

 Table 1: Summary of Assumptions & Adjustments for Calculation of First Year Potential Tax
Revenues
Illegal market price (estimated average)
Illegal market sales (estimated)
Estimated illegal market size
Estimated legal market price (excluding taxes)
Price elasticity of demand
Non-price effect of legalization
Marijuana retail tax rate

$270 and $340 per ounce
6.5 -10.2 million ounces
$1.7 billion - $3.5 billion
$297 and $374 per ounce
-0.8
+5 percent
7 percent and 15 percent

Based on this analysis, the estimated potential total
tax revenue in the first year with a price of $297
and illegal market consumption of 6.5 million
ounces ranges from $248.1 million (with a 7% tax
rate) to $340.6 million (with a 15% tax rate). The
estimated potential total tax revenue with a price of

$374 and illegal market consumption of 10.2 million
ounces ranges from $493.7 million (with a 7% tax
rate) to $677.7 million (with a 15% tax rate). The
table below shows the results of applying these
inputs and adjustments (see Table 2 below).

Table 2: Retail Price/Retail Tax
$297 per ounce
Sales and Tax
Revenues
Retail Sales

$374 per ounce

7%
$1.6 billion

15%
$1.4 billion

7%
$3.1 billion

15%
$2.9 billion

$110.3 million

$215.2 million

$219.5 million

$428.1 million

State and Local Sales
Tax

$137.8 million

$125.4 million

$274.2 million

$249.6 million

Total Tax revenues

$248.1 million

$340.6 million

$493.7 million

$677.7 million

Marijuana Retail Tax

This analysis assumes that a portion of sales remain in the illegal market. Over time, the number of
users remaining in the illegal market may decline.

19

 changing budgetary needs of law enforcement.
Subject matter experts identified evaluation as a
priority, stating that it would be irresponsible if NYS
does not add to the knowledge around regulated
marijuana programming. The availability of State
funding for research would remove some of the
limitations associated with research using federal
dollars.

The projection of potential tax revenues is a
preliminary estimate based on numerous
assumptions. Further analyses should
account for possible variations in the values
of assumptions used here, which reflect
uncertainties in pricing, consumption, and
the effect of legalization on the unregulated
market. This analysis also reflects
uncertainty as to whether lower prices
resulting from legalization will cause users
to move to the regulated market. Further,
given that there is some uncertainty in all
parameters used in the analyses described
here, these point estimate results should be
considered careful and reasonable
estimates based on the best available
literature. As any regulated marketplace
unfolds, such analyses should be routinely
updated over time.

NYS should follow certain best practices based on
lessons learned in other states in implementing a
tax on regulated marijuana use and the differing
taxing options. Some states had to lower their
initial tax rate since a higher price did not
incentivize consumers to move from the
unregulated to the legal market. If a significant price
difference exists between recreational and medical
marijuana, consumers will likely prefer the lower
price product which is why the ability to adjust or
index tax rates to address realities in the market has
proven beneficial. For example, a bill put forward in
New Jersey proposes a graduated marijuana retail
tax. The retail tax begins at a rate of 7 percent in
the first year to encourage consumers to transition
from the unregulated market. Over the course of
five years, in conjunction with a maturing industry,
the tax rate increases to 25 percent.114 Some states
overestimated revenue initially, as they did not
account for the length of time it takes for a
recreational marijuana market to become
established, leading to fewer than expected sales.

Tax revenue can support State program
initiatives.
According to the Colorado Department of Revenue,
marijuana sales generated nearly $200 million in
State tax revenue and license fees in 2016.
Colorado’s Marijuana Tax Cash Fund is used for
school construction, expanded education, drug
prevention efforts and law enforcement. Since
municipalities have the choice to participate in the
legal market, only participating local governments
receive money from the Fund.113 Washington State
uses the funds generated from marijuana sales to
aid administrative costs, research projects,
substance abuse programs, marijuana programs,
health care, and the State’s general fund. Appendix
A, Figure 5 illustrates the use of revenue from
regulated marijuana and the employment that
resulted from legalized marijuana in the State of
Colorado.

The three main ways of taxing marijuana are
weight-based, price-based and potency-based. A
weight based tax is best to be implemented at the
producer level and has the advantages of reducing
product leakage into the untaxed market, creating a
price floor, and allowing for a more stable revenue
stream. However, it also incentivizes higher
potencies and is more difficult to administer. A
retail price-based tax has proven most effective as it
is easier to administer and less problematic than a
producer or wholesale level tax, but it is a more
unstable revenue source. A potency-based tax
system best correlates to the level of intoxication
(similar to alcohol taxation), yet current testing
methods may be inadequate for taxation purposes

➢ Subject matter experts agreed that there is
potential for substantial tax revenue in NYS, which
can be used for the greater good, such as public
health, education, transportation, addressing the
needs of a changing workforce, and addressing the

20

 and it could be a more complex tax system to
establish and administer.

Prioritization should be given to an educational
approach that emphasizes safety, mitigates
potential harm, and suggests that youth delay
use.116 Evidence suggests that prevention strategies
targeting youth can be most effective if they
provide honest, science-based information in a nonjudgmental and non-punitive manner.117 Enhancing
youth skills such as personal responsibility and
knowledge is essential. While abstinence must be
encouraged, youth should be taught to understand
that moderation and self-regulation can mitigate
potential harms if they do not abstain.118

In addition, there are other inherent risks that will
impact the amount of potential revenue
collected. These include allowing individuals to
grow a certain amount of marijuana plants, placing
a limit on the amount purchased or allowing
localities to ban the sale of marijuana, which will all
lead to an increase of marijuana purchased on the
unregulated market and will reduce the amount of
tax collected. Also, the strains of marijuana and
forms permissible will have an impact on sales. The
restrictive nature of current regulations on medical
marijuana will also need to be addressed, as well as
whether there should be a tax break for those using
marijuana for medicinal purposes since both will
have a direct impact on the tax amount collected.

Research indicates that states need to address
adolescents' perceptions of the risks, benefits,
social norms, and peer influences surrounding
marijuana use as they implement strategies to
reduce youth use of marijuana.119 In Washington
State, surveys of 8th and 10th graders indicated that
they perceived marijuana as being less harmful
after legalization.120 The same was not true in
Colorado, where there was no change in adolescent
perception of harmfulness post legalization.121

Tax revenue from regulated marijuana can
be used to support program initiatives in
areas such as public health education,
transportation, research, law enforcement,
workforce development and community
reinvestment.

Regulating marijuana enables public
health officials to share messages
regarding lower risk cannabis use
guidelines (LRCUG) to help reduce the
potential harms of marijuana
consumption.122

IV. Education

In a regulated marijuana program, products can
be labeled to indicate the percentages of the
various chemical compounds they contain (e.g.,
CBD vs. THC content) to maximize consumer
awareness of potency. Research indicates that
issuing guidelines on the following can help
ameliorate the potential harms of marijuana use:
avoiding combustible use, avoiding use when
pregnant, making products with lower potency
available, prohibiting youth use, and avoiding
consumption of marijuana and tobacco in
tandem. Further messaging should be provided to
ensure that individuals know about the
differences between marijuana use, tobacco use
and alcohol use, as well as to ensure that

Public safety messaging is needed to
ensure individuals know about the potential
harms of drugged driving.
Individuals who consume marijuana are more likely to
perceive the risks of marijuana intoxication while
driving as lower than individuals who do not consume
marijuana.115 Public safety messaging and ongoing
monitoring are required to educate the public.
Marijuana messaging should be tailored
to the needs of different key populations
including youth/adolescents/young
adults and pregnant women.

21

 individuals exercise caution not to consume
multiple substances at once.

V. Impact of Legalization on
Other States

States with legalized marijuana have
conducted extensive educational
campaigns as their programs were
implemented.
Concerns have been raised by government
representatives about the impact of legalized
marijuana on the workforce and the need for
workforce training. For example, Child Protective
Services workers would require training on the
appropriate response to a positive screen for
marijuana in newborns and mothers if it is no
longer illegal. There will be implications for
substance use treatment providers. A strategy will
be needed for providers who will be required to
treat substance use in an environment where
marijuana is legal. There is likely to be a need for
education for the judiciary and treatment courts.

The legalization of marijuana in neighboring
jurisdictions raises concerns about both marijuana
diversion to NYS from states that have legalized and
revenue diversion from NYS to states that have
legalized. Several neighboring jurisdictions have
legalized marijuana or are likely to legalize soon.
Massachusetts, Vermont, Maine and Canada have
legalized marijuana. Legalization is under
discussion in New Jersey as well.
Regarding diversion of marijuana from states with
legal markets, a University of Oregon study
demonstrates that areas legalizing marijuana will
likely sell sizable quantities of marijuana to
individuals from neighboring regions. Oregon
opened a regulated market on October 1, 2015,
next to Washington State’s existing market. The
study found that Washington retailers along the
Oregon border experienced a 41 percent decline in
sales following Oregon’s legal market opening. The
study found evidence that prior to legalization in
Oregon, consumers on the Oregon side of the
border were crossing state lines to obtain marijuana
in Washington rather than purchase marijuana in
Oregon through the unregulated market. This is
particularly striking given the fact that obtaining
marijuana illegally in Oregon resulted in only a civil
fine, whereas crossing state lines to obtain legal
marijuana in Washington risked federal felony
prosecution. The study suggests that consumers
prefer legal, regulated products, perhaps due to the
variety of products offered, the presence of safety
regulations, and the additional product attribute
information stemming from THC and CBD testing.123

➢ Subject matter experts noted the need for training
for public housing and substance use treatment
workers, since marijuana use is punished in a
criminalized environment. There would need to be
education on dismantling punitive measures.
Legalization provides an opportunity to
educate consumers on what their
options are and encourage the use of
products with lower doses of THC.
People will be empowered to take more
control over their mental and physical health if
they are given counsel and guidance. There are
opportunities to provide such guidance in a
regulated market.

Legalization in surrounding jurisdictions could lead
to an increase in marijuana possession arrests in
border counties in NYS. A Washington State
University study examined the “spillover” effects of
regulated marijuana legalization in Colorado and
Washington on neighboring states without

22

 legalization and found that legalization causes a
sharp increase in marijuana possession arrests in
border counties of neighboring states relative to
non-border counties in these states. Regulating
marijuana has no impact on juvenile marijuana
possession arrests but is rather fully concentrated
among adults.124

VI. Implementation
The overarching goal of regulating marijuana in NYS
must be the incorporation of harm reduction
strategies. Implementation of a regulated
marijuana program will require considerable
planning as to the regulatory mechanisms needed
to protect public health, provide consumer
protection, and ensure public safety. At the same
time, a well thought out program should address
the social justice issues associated with
criminalization, provide opportunity for community
revitalization, and establish a system to capture and
invest tax revenue. Ultimately, the system should
be designed to reduce the utilization of the
unregulated market. Implementation of a regulated
marijuana program will require legislative and
regulatory approaches that address the diverse
needs of the State and the differing needs of a
regulated marijuana program in rural regions
compared to those in urban areas.

Notably, unlike other states that shared one border
with a state that legalized, New York shares
multiple borders with states that have or are
considering legalized marijuana (i.e.,
Massachusetts, Vermont and New Jersey) and one
international border (New York shares a border
with two Canadian provinces). If marijuana is not
legalized, the cross-border effects in NYS are likely
to be substantial, involving numerous counties and
municipalities.
Legalization in neighboring jurisdictions raises the
likelihood of revenue flowing from New York into
those jurisdictions. The methodology used in a joint
New Jersey Policy Perspective/New Jersey United
for Marijuana Reform analysis of revenue
implications of legalized marijuana in New Jersey
includes estimates associated with non-New Jersey
participants, specifically residents of New York and
Pennsylvania, in their marijuana marketplace. The
projected annual expenditures of New York and
Pennsylvania consumers in New Jersey’s market is
estimated at $108.7 million.125

A key substantive policy area is the determination
of the types of licenses to be granted in a regulated
marijuana program. Other states have various subclassifications of licenses, but they generally fall
within classifications such as: cultivation/producer,
manufacturing/processor, testing, retail, and
distribution. California has 13 types of cultivation
licenses alone, varying based on size, indoor,
outdoor, nursery, microbusiness, etc.126
Massachusetts is prioritizing applicants for licensure
to ensure equal opportunities in the regulated
market for individuals who meet certain criteria,
including ownership by or the provision of services
to persons who live in areas of disproportionate
impact, employment of residents of areas of
disproportionate impact, employment of people
with drug-related criminal offender record
information who are otherwise employable, and
ownership by persons of color.127 Many states offer
producer licenses at different tiers based on the

➢ Subject matter experts noted that failure to
legalize in NYS could increase unregulated market
sales if persons buy marijuana legally in
surrounding jurisdictions to re-sell it illegally in
NYS.

23

 canopyXIII of their potential cultivation.128 Fee
structures for the applications of these licenses and
the licenses themselves will also need to be
determined. Further consideration is needed to
determine who will review and issue licenses and
how often they will need to be updated. We
recommend that NYS limit the number of licenses
initially available and adopt a model of licensure
prioritization similar to the Massachusetts model.

guidance solely regarding the specifics of product
packaging. Requirements regarding child proofing
and tamper proofing will also need to be
determined. To ensure packaging is not attractive to
minors, we recommend that the program include
guidelines to standardize the industry (such as
avoiding cartoon-like imagery or requiring that any
products that may look like candy be contained in
opaque packaging). We also recommend that
processes be established to approve packaging for
marijuana products, and guidelines will be required
to set forth specific packaging parameters.

In addition to licensure regulations, the State will
need to establish further requirements for each
step of the supply chain. It is imperative to decouple
the regulated marijuana program from both the
alcohol and tobacco industries, thus ensuring that
they are not involved in any step along the supply
chain. With respect to cultivation and production,
regulations will be required to control the amount
and location of production (e.g., indoors or
outdoors). With respect to testing, guidance will be
needed for laboratories to ascertain the breakdown
of THC and CBD content and to test for mold and
other contaminants. Regulations will also be
required to address how marijuana will be retailed,
including the types of products that can be sold in
the market and locations of sales dispensaries (e.g.,
distance from schools, churches, etc.). Alaska,
Massachusetts, and Nevada have established
regulations to ensure that substances would not be
plainly visible to the public from outside retail
establishments.

Another key substantive policy area is the taxation
of regulated marijuana products, which has many
implications as taxation dictates the price of the
products in the regulated market, influencing
consumer behavior. As discussed in the Economic
Estimates section of this report, price point is
crucial because if it is too high, consumers will not
transition from the unregulated market to the
regulated market.129 Decisions will need to be made
about where in the production chain excise taxes
are placed and to what extent each level of
production should be taxed. We recommend that
the state begin with low taxation (e.g. between 7
and 10 percent.) NYS will need to determine if
vertical integration will be permitted. NYS should
consider lessons learned in other states.
Washington State initially had higher tax rates and
restructured their taxation after the realization that
the taxes were cost prohibitive. Colorado,
Washington, and Oregon have all taken steps to
reduce their marijuana tax rates.130 Ensuring that
NYS has adequate pricing will require careful and
intentional deliberations with numerous
stakeholders. The economic estimates in this
assessment are based on numerous assumptions
and are intended to provide a framework for
further discussion.

Additionally, regulations will be required to
determine what will be permitted for specific
products. This includes detailed discussion
regarding the appropriate amount of THC per
serving size and what types of products would be
permitted (flower, vaporization, edibles, tinctures,
topicals, etc.). We recommend that NYS place limits
on the amount of THC and the types of products
offered for sale. We recommend that the amount of
marijuana that may be purchased be limited to a
one-ounce maximum. Other states, such as Oregon,
have conducted focus groups and established

A regulated marijuana program should ensure that
workforce needs are met. Safe working
environments should be established for individuals

XIII

Washington State defines canopy as the square
footage dedicated to live plant production, such as
maintaining mother plants, propagating plants from seed
to plant tissue, clones, vegetative or flowering area. Plant

canopy does not include areas such as space used for the
storage of fertilizers, pesticides, or other products,
quarantine, office space, etc.

24

 in the new regulated market. Labor protections will
need to address both cultivation and retail and
include special considerations for indoor and
outdoor cultivation. Businesses in Colorado’s
marijuana industry must comply with the
regulations and recordkeeping requirements of the
Occupational Safety and Health Administration
(OSHA). Colorado’s Guide to Worker Safety and
Health in the Marijuana Industry: 2017 delineates
the federal OSHA requirements, state regulations,
and a best practice guide to ensure worker safety.
Specific protections apply to different classifications
of occupations including cultivators, trimmers,
technicians, administrators, edible producers, and
transporters. Colorado outlined protections against
biological hazards (i.e., mold and allergens) and
chemical hazards (i.e., pesticides, nutrients, and
disinfectants) and laid out specific workers’ rights
for individuals working in any component of the
marijuana industry. We recommend that NYS
similarly adopt regulations regarding training for
individuals working in the industry.

established educational campaigns to notify the
public of the details of the legislative change and
educate them about marijuana use. NYS should
consider creating statewide educational campaigns
to prepare the public and inform consumers before
dispensaries are operational. As noted in the
Education section of this report, educational
campaigns should consider key populations, such as
individuals with or at risk for severe mental illness,
youth, and pregnant and breastfeeding women.
We recommend NYS address prior criminal
convictions for marijuana possession. Some
jurisdictions are working toward expunging
previous drug-related offenses, such as San
Francisco and San Diego, where district attorneys
announced that they will review, recall, resentence,
potentially dismiss, and seal misdemeanor and
felony marijuana convictions. Seattle’s district
attorney made a similar announcement. This will
have lasting social justice implications, as there has
been disproportionate criminalization of certain
racial and ethnic groups. We recommend NYS
expunge the criminal records of individuals with
marijuana-related offenses.

A regulated marijuana program should consider
mandating data collection and evaluation of its
impact. Information obtained from ongoing studies
should be used to further refine the State’s
regulatory approach and inform program design so
NYS can respond to needs as they arise. NYS has an
opportunity to be a leader in monitoring the use of
marijuana and gathering information about benefits
and potential harm to inform the implementation of
harm reduction strategies. We recommend that NYS
establish a comprehensive system of data collection
at point-of-sale.

All states that have legalized have had to address
specific and important issues when implementing a
regulated marijuana program. An analysis of each
state’s decisions with respect to the detailed
regulations they have issued may be found in
Appendix C. Similar regulations and guidance will
need to be created in NYS through careful planning
with policy makers and subject matter experts if
NYS moves toward implementation.

A regulated marijuana program will require detailed
guidance in the areas of public safety and
education. Enforcement regulations will need to be
created for general oversight, inspection, and
penalties for participants who engage in
unregulated sale or use. We recommend that NYS
create statewide educational campaigns to continue
ensuring the safety of the State’s roads and public
safety messaging that is targeted to specific
populations. Peer education will be essential, and it
will be important to develop tools to assist parents
in communicating with their children. Other states
with regulated marijuana programs have

It is important to understand that effective
implementation and regulation will be an ongoing
process that will take continued work from State
and local officials. Every step of a regulated
marijuana program will require planning and
regulation. Thoughtful input will be required on the
development of legislation, regulations, policies,
and implementation strategies. In addition, precise
technical guidelines will need to be developed in
public health, public safety, and consumer
protection to ultimately ensure the program is
established with a harm reduction approach.

25

 Participation of stakeholders in developing the
parameters of a regulated marijuana program is
important. Such stakeholders could include subject
matter experts from throughout the State and
government representatives of public health,
mental health, substance use, taxation and finance,
law enforcement, and public safety. Moving
forward, it is recommended that NYS form a
workgroup of subject matter experts with relevant
public health expertise to consider the nuances of a
regulated marijuana program, review existing
legislation, and make recommendations to the State
that address each of these areas in a manner that is
consistent with the harm reduction goal.

program effectiveness. Policymakers can learn
lessons from approaches taken by other states and
study what has worked and what has not.
There are tradeoffs inherent to the transition from
an unregulated to a regulated market. It is
imperative that a regulated marijuana program
contain all necessary safeguards and measures to
limit access for individuals under 21, minimize
impaired driving, provide education and tailored
messaging to different populations, and connect
people to treatment if needed. During this
transition, the purpose of public policy will be to
reduce the harms associated with marijuana
criminalization, minimize the harms associated with
a regulated marijuana program, and maximize the
benefits of regulation.

The process of legalization and regulation will be
dynamic. Legalization efforts should be clear on the
goals they are setting out to achieve for the people
of NYS. Policymakers will need to balance
competing priorities in a way that maximizes

26

 VI. Conclusion
The positive effects of a regulated marijuana market in NYS outweigh the potential
negative impacts. Areas that may be a cause for concern can be mitigated with
regulation and proper use of public education that is tailored to address key
populations. Incorporating proper metrics and indicators will ensure rigorous and
ongoing evaluation.
•

•

•

can also support community reinvestment in
health care and employment.

Numerous NYS agencies and subject matter
experts in the fields of public health, mental
health, substance use, public safety,
transportation, and economics worked in
developing this assessment. No
insurmountable obstacles to regulation of
marijuana were raised.
Regulation of marijuana benefits public health
by enabling government oversight of the
production, testing, labeling, distribution, and
sale of marijuana.131 The creation of a
regulated marijuana program would enable
NYS to better control licensing, ensure quality
control and consumer protection, and set age
and quantity restrictions.
NYS would be one of the largest potential
regulated marijuana markets in the United
States. As such, there is potential for
substantial tax revenue in NYS, which can be
used to help support program initiatives in
areas such as public health, education,
transportation, research, law enforcement
and workforce development. Tax revenues

27

•

Historically, marijuana criminalization has had
a profound impact on communities of color
and has led to disproportionate targeting of
certain populations for arrest and
prosecution. The over-prosecution of
marijuana has significant negative economic,
health, and safety impacts that have
disproportionately affected low-income
communities of color. Legalization of
marijuana will address this important social
justice issue.

•

The development of this assessment involved
discussions of numerous issues that relate to
implementation of a legalized marijuana
program, rather than the impact. Much of the
impact of a regulated marijuana program is
contingent on program implementation.
While some implementation issues have been
described in this assessment, further
exploration will be required should NYS move
toward legalization.

 Appendix A: Figures, Graphs and Charts
Figure 1: Map of State Marijuana Policies

Source: “U.S. Legalized Cannabis Map.” Cannabis Compliance, tgunthergroup.com/2017-cannabis-map/.

28

 Figure 2: Past Month Marijuana Use, Aged 12-17, New York

Source: SAMHSA National Survey on Drug Use and Health, 2002 – 2016.

Figure 3: Past Month Marijuana Use, Aged 18+, New York

Source: SAMHSA National Survey on Drug Use and Health, 2002 – 2016.

29

  

Figure 4: Colorado Economic Development and Job Creation

Figure 6.
Employment
estimates by type
In Colorado, 2015

Source:

Marijuana Group.

Employment in Colorado
Caused by Legalized Marijuana

2014 2015

9,936 Direct (FTE)
iobs employment created

2.. Indirect employment 
late created . 

Induced employment 
1" created jute

Statewrde employment
created

1 4,209
gobs

1 8,005
robs

Number of direct employees
by industry segment (FTE)


4,407 Retarloperattons

2,770 
2,015 
1,889 3/ Management



Manufacturing

1 ,51 1 Ha Agnculture 

 

 

Figure 5: Marijuana Tax Revenue Usage in Colorado

 

Marijuana Enforcement 8.
Licensing


(separatety funded)

 

Mil marijuanawu taxed 312.9%. bum

duobaapocialuloouxhcromlrom
1096101596 emotive Jury 1.2017. This


 

Source: Cobrodo Logislalvo sun 
Economic Facade 2017



Appendix B: Annotated Bibliography
Introduction
The annotated bibliography that follows contains a select group of journal articles related to marijuana use and
the impact of legalization. This bibliography was developed by conducting an extensive search of Englishlanguage literature indexed in PubMed (http://pubmed.gov), an online database of biomedical journal citations
and abstracts created by the U.S. National Library of Medicine and Google Scholar, an online search engine that
provides journal articles and research from academic publishers, professional societies, universities, and other
web sites.
Many of the articles selected contain overlapping information touching on some or all of the following focus
areas: Health, Criminal Justice and Public Safety, Economic, and Education.

Health
Adejumo, A. C., Ajayi, T. O., Adegbala, O. M., Adejumo, K. L., Alliu, S., Akinjero, A. M., . . . Bukong, T. N. (2018).
Cannabis Use is Associated with Reduced Prevalence of Progressive Stages of Alcoholic Liver Disease. Liver
International. doi:10.1111/ liv.13696.
Background: Abusive alcohol use has well-established health risks including causing liver disease (ALD)
characterized by alcoholic steatosis (AS), steatohepatitis (AH), fibrosis, cirrhosis (AC) and hepatocellular
carcinoma (HCC). Strikingly, a significant number of individuals who abuse alcohol also use Cannabis, which has
seen increased legalization globally. While cannabis has demonstrated anti-inflammatory properties, its
combined use with alcohol and the development of liver disease remain unclear. Aim: The aim of this study
was to determine the effects of cannabis use on the incidence of liver disease in individuals who abuse alcohol.
Methods: We analysed the 2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS)
discharge records of patients 18 years and older, who had a past or current history of abusive alcohol use
(n = 319 514). Using the International Classification of Disease, Ninth Edition codes, we studied the four distinct
phases of progressive ALD with respect to three cannabis exposure groups: non-cannabis users (90.39%), nondependent cannabis users (8.26%) and dependent cannabis users (1.36%). We accounted for the complex survey
sampling methodology and estimated the adjusted odds ratio (AOR) for developing AS, AH, AC and HCC with
respect to cannabis use (SAS 9.4). Results: Our study revealed that among alcohol users, individuals who
additionally use cannabis (dependent and non-dependent cannabis use) showed significantly lower odds of
developing AS, AH, AC and HCC (AOR: 0.55 [0.48-0.64], 0.57 [0.53-0.61], 0.45 [0.43-0.48] and 0.62 [0.51-0.76]).
Furthermore, dependent users had significantly lower odds than non-dependent users for developing liver
disease. Conclusions: Our findings suggest that cannabis use is associated with a reduced incidence of liver
disease in alcoholics.
Bachhuber, M. A., Saloner, B., Cunningham, C. O., & Barry, C. L. (2014). Medical Cannabis Laws and Opioid
Analgesic Overdose Mortality in the United States, 1999-2010. JAMA Internal Medicine, 174(10), 1668.
doi:10.1001/jamainternmed.2014.4005.
Importance: Opioid analgesic overdose mortality continues to rise in the United States, driven by increases in
prescribing for chronic pain. Because chronic pain is a major indication for medical cannabis, laws that establish
access to medical cannabis may change overdose mortality related to opioid analgesics in states that have

32

 enacted them. Objective: To determine the association between the presence of state medical cannabis laws
and opioid analgesic overdose mortality. Design, Setting, and Participants: A time-series analysis was
conducted of medical cannabis laws and state-level death certificate data in the United States from 1999 to
2010; all 50 states were included. Exposures: Presence of a law establishing a medical cannabis program in the
state. Main Outcomes and Measures: Age-adjusted opioid analgesic overdose death rate per 100 000 population
in each state. Regression models were developed including state and year fixed effects, the presence of 3
different policies regarding opioid analgesics, and the state-specific unemployment rate. Results: Three states
(California, Oregon, and Washington) had medical cannabis laws effective prior to 1999. Ten states (Alaska,
Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) enacted
medical cannabis laws between 1999 and 2010. States with medical cannabis laws had a 24.8% lower mean
annual opioid overdose mortality rate (95% CI, −37.5% to −9.5%; P = .003) compared with states without medical
cannabis laws. Examination of the association between medical cannabis laws and opioid analgesic overdose
mortality in each year after implementation of the law showed that such laws were associated with a lower rate
of overdose mortality that generally strengthened over time: year 1 (−19.9%; 95% CI, −30.6% to −7.7%; P = .002),
year 2 (−25.2%; 95% CI, −40.6% to −5.9%; P = .01), year 3 (−23.6%; 95% CI, −41.1% to −1.0%; P = .04), year 4
(−20.2%; 95% CI, −33.6% to −4.0%; P = .02), year 5 (−33.7%; 95% CI, −50.9% to −10.4%; P = .008), and year 6
(−33.3%; 95% CI, −44.7% to −19.6%; P < .001). In secondary analyses, the findings remained similar. Conclusions
and Relevance: Medical cannabis laws are associated with significantly lower state-level opioid overdose
mortality rates. Further investigation is required to determine how medical cannabis laws may interact with
policies aimed at preventing opioid analgesic overdose.
Boehnke, K. F., Litinas, E., & Clauw, D. J. (2016). Medical Cannabis Use Is Associated with Decreased Opiate
Medication Use in a Retrospective Cross-Sectional Survey of Patients with Chronic Pain. The Journal of Pain,
17(6), 739-744. doi:10.1016/j.jpain.2016.03.002.
Abstract: Opioids are commonly used to treat patients with chronic pain (CP), though there is little evidence
that they are effective for long term CP treatment. Previous studies reported strong associations between
passage of medical cannabis laws and decrease in opioid overdose statewide. Our aim was to examine whether
using medical cannabis for CP changed individual patterns of opioid use. Using an online questionnaire, we
conducted a cross-sectional retrospective survey of 244 medical cannabis patients with CP who patronized a
medical cannabis dispensary in Michigan between November 2013 and February 2015. Data collected included
demographic information, changes in opioid use, quality of life, medication classes used, and medication side
effects before and after initiation of cannabis usage. Among study participants, medical cannabis use was
associated with a 64% decrease in opioid use (n = 118), decreased number and side effects of medications, and
an improved quality of life (45%). This study suggests that many CP patients are essentially substituting medical
cannabis for opioids and other medications for CP treatment, and finding the benefit and side effect profile of
cannabis to be greater than these other classes of medications. More research is needed to validate this finding.
Perspective: This article suggests that using medical cannabis for CP treatment may benefit some CP patients.
The reported improvement in quality of life, better side effect profile, and decreased opioid use should be
confirmed by rigorous, longitudinal studies that also assess how CP patients use medical cannabis for pain
management.
Bonar, E. E., Goldstick, J. E., Collins, R. L., Cranford, J. A., Cunningham, R. M., Chermack, S. T., . . . Walton, M.
A. (2017). Daily associations between cannabis motives and consumption in emerging adults. Drug and
Alcohol Dependence, 178, 136-142. doi:10. 1016/j.drugalcdep.2017.05.006.
Background: Increasing rates of cannabis use among emerging adults is a growing public health problem.
Intensive longitudinal data can provide information on proximal motives for cannabis use, which can inform

33

 interventions to reduce use among emerging adults. Method: As part of a larger longitudinal study, patients
aged 18-25 years (N=95) recruited from an urban Emergency Department completed daily text message
assessments of risk behaviors for 28 days, including daily cannabis quantity and motives. Using a mixed effects
linear regression model, we examined the relationships between daily quantity of cannabis consumed and
motives (i.e., enhancement, social, conformity, coping, and expansion). Results: Participants were, on average,
22.0 years old (SD=2.2); 48.4% were male, 45.3% were African American, and 56.8% received public assistance.
Results from the multi-level analysis (clustering day within individual), controlling for gender, race, and receipt
of public assistance, indicated daily use of cannabis use for enhancement (β=0.27), coping (β=0.15), and/or
social motives (β=0.34) was significantly associated with higher quantities of daily cannabis use; whereas
expansion and conformity motives were not. Conclusions: Daily data show that emerging adults who use
cannabis for enhancement, social, and coping motives reported using greater quantities of cannabis. Future
research should examine more comprehensive cannabis motives (e.g., boredom, social anxiety, sleep) and test
tailored interventions focusing on alternative cognitive/behavioral strategies to address cannabis motives.
Bradford, A. C., & Bradford, W. D. (2016). Medical Marijuana Laws Reduce Prescription Medication Use in
Medicare Part D. Health Affairs, 35(7), 1230-1236. doi:10.1377/ hlthaff.2015.1661.
Abstract: Legalization of medical marijuana has been one of the most controversial areas of state policy change
over the past twenty years. However, little is known about whether medical marijuana is being used clinically to
any significant degree. Using data on all prescriptions filled by Medicare Part D enrollees from 2010 to 2013, we
found that the use of prescription drugs for which marijuana could serve as a clinical alternative fell significantly,
once a medical marijuana law was implemented. National overall reductions in Medicare program and enrollee
spending when states implemented medical marijuana laws were estimated to be $165.2 million per year in
2013. The availability of medical marijuana has a significant effect on prescribing patterns and spending in
Medicare Part D.
Bradford, A. C., Bradford, W. D., Abraham, A., & Adams, G. B. (2018). Association Between US State Medical
Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Internal Medicine.
doi:10.1001/jamainternmed.2018.0266.
Importance: Opioid-related mortality increased by 15.6% from 2014 to 2015 and increased almost 320%
between 2000 and 2015. Recent research finds that the use of all pain medications (opioid and nonopioid
collectively) decreases in Medicare Part D and Medicaid populations when states approve medical cannabis laws
(MCLs). The association between MCLs and opioid prescriptions is not well understood. Objective: To examine
the association between prescribing patterns for opioids in Medicare Part D and the implementation of state
MCLs. Design, Setting, and Participants: Longitudinal analysis of the daily doses of opioids filled in Medicare
Part D for all opioids as a group and for categories of opioids by state and state-level MCLs from 2010 through
2015. Separate models were estimated first for whether the state had implemented any MCL and second for
whether a state had implemented either a dispensary-based or a home cultivation only-based MCL. Main
Outcomes and Measures: The primary outcome measure was the total number of daily opioid doses prescribed
(in millions) in each US state for all opioids. The secondary analysis examined the association between MCLs
separately by opioid class. Results: From 2010 to 2015 there were 23.08 million daily doses of any opioid
dispensed per year in the average state under Medicare Part D. Multiple regression analysis results found that
patients filled fewer daily doses of any opioid in states with an MCL. The associations between MCLs and any
opioid prescribing were statistically significant when we took the type of MCL into account: states with active
dispensaries saw 3.742 million fewer daily doses filled (95% CI, -6.289 to -1.194); states with home cultivation
only MCLs saw 1.792 million fewer filled daily doses (95% CI, -3.532 to -0.052). Results varied by type of opioid,
with statistically significant estimated negative associations observed for hydrocodone and morphine.

34

 Hydrocodone use decreased by 2.320 million daily doses (or 17.4%) filled with dispensary-based MCLs (95% CI, 3.782 to -0.859; P = .002) and decreased by 1.256 million daily doses (or 9.4%) filled with home-cultivation-onlybased MCLs (95% CI, -2.319 to -0.193; P = .02). Morphine use decreased by 0.361 million daily doses (or 20.7%)
filled with dispensary-based MCLs (95% CI, -0.718 to -0.005; P = .047). Conclusions and Relevance: Medical
cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population.
This finding was particularly strong in states that permit dispensaries, and for reductions in hydrocodone and
morphine prescriptions.
Chen, H., & Searles, J. S. (2017). Health Considerations in Regulating Marijuana in Vermont. Preventive
Medicine, 104, 7-9. doi:10.1016/j.ypmed.2017.06.004.
Abstract: This article delineates the current efforts of the Vermont Department of Health (VDH) to address the
potential health impact of legalization and regulation of recreational marijuana for use by adults at least 21years
of age. To this end, VDH and key stakeholders developed and published a Health Impact Assessment with
specific recommendations should legislation that legalized and regulated marijuana be passed into law.
Although the legalization legislation failed in 2016 and was vetoed by the Governor in 2017, it is unclear what
will happen in the future.
Gunn, J. K., Rosales, C. B., Center, K. E., Nuñez, A., Gibson, S. J., Christ, C., & Ehiri, J. E. (2016). Prenatal
Exposure to Cannabis and Maternal and Child Health Outcomes: A Systematic Review and Meta-Analysis. BMJ
Open, 6(4). doi:10.1136/bmjopen-2015-009986.
Objective: To assess the effects of use of cannabis during pregnancy on maternal and fetal outcomes. Data
Sources: 7 electronic databases were searched from inception to 1 April 2014. Studies that investigated the
effects of use of cannabis during pregnancy on maternal and fetal outcomes were included. Study Selection:
Case-control studies, cross-sectional and cohort studies were included. Data Extraction and Synthesis: Data
synthesis was undertaken via systematic review and meta-analysis of available evidence. All review stages were
conducted independently by 2 reviewers. Main Outcomes and Measures: Maternal, fetal and neonatal
outcomes up to 6 weeks postpartum after exposure to cannabis. Meta-analyses were conducted on variables
that had 3 or more studies that measured an outcome in a consistent manner. Outcomes for which metaanalyses were conducted included: anaemia, birth weight, low birth weight, neonatal length, placement in the
neonatal intensive care unit, gestational age, head circumference and preterm birth. Results: 24 studies were
included in the review. Results of the meta-analysis demonstrated that women who used cannabis during
pregnancy had an increase in the odds of anaemia (pooled OR (pOR)=1.36: 95% CI 1.10 to 1.69) compared with
women who did not use cannabis during pregnancy. Infants exposed to cannabis in utero had a decrease in birth
weight (low birth weight pOR=1.77: 95% CI 1.04 to 3.01; pooled mean difference (pMD) for birth weight=109.42
g: 38.72 to 180.12) compared with infants whose mothers did not use cannabis during pregnancy. Infants
exposed to cannabis in utero were also more likely to need placement in the neonatal intensive care unit
compared with infants whose mothers did not use cannabis during pregnancy (pOR=2.02: 1.27 to 3.21).
Conclusions: Use of cannabis during pregnancy may increase adverse outcomes for women and their neonates.
As use of cannabis gains social acceptance, pregnant women and their medical providers could benefit from
health education on potential adverse effects of use of cannabis during pregnancy.
Hall, W. (2017). Alcohol and Cannabis: Comparing Their Adverse Health Effects and Regulatory Regimes.
International Journal of Drug Policy, 42, 57-62. doi:10.1016/ j.drugpo.2016.10.021.
Abstract: The claim that the adverse health effects of cannabis are much less serious than those of alcohol has
been central to the case for cannabis legalisation. Regulators in US states that have legalised cannabis have

35

 adopted regulatory models based on alcohol. This paper critically examines the claim about adverse health
effects and the wisdom of regulating cannabis like alcohol. First, it compares what we know about the adverse
health effects of alcohol and cannabis. Second, it discusses the uncertainties about the long term health effects
of sustained daily cannabis use. Third, it speculates about how the adverse health effects of cannabis may
change after legalisation. Fourth, it questions the assumption that alcohol provides the best regulatory model
for a legal cannabis market. Fifth, it outlines the major challenges in regulating cannabis under the liberal
alcohol-like regulatory regimes now being introduced.
Hall, W., & Weier, M. (2015). Assessing the public health impacts of legalizing recreational cannabis use in the
USA. Clinical Pharmacology & Therapeutics, 97(6), 607-615. doi:10.1002/cpt.110.
A major challenge in assessing the public health impact of legalizing cannabis use in Colorado and Washington
State is the absence of any experience with legal cannabis markets. The Netherlands created a de facto legalized
cannabis market for recreational use, but policy analysts disagree about how it has affected rates of cannabis
use. Some US states have created de facto legal supply of cannabis for medical use. So far this policy does not
appear to have increased cannabis use or cannabis-related harm. Given experience with more liberal alcohol
policies, the legalization of recreational cannabis use is likely to increase use among current users. It is also likely
that legalization will increase the number of new users among young adults but it remains uncertain how many
may be recruited, within what time frame, among which groups within the population, and how many of these
new users will become regular users.
Hasin, D. S., Saha, T. D., Kerridge, B. T., Goldstein, R. B., Chou, S. P., Zhang, H., . . . Grant, B. F. (2015).
Prevalence of Marijuana Use Disorders in the United States Between 2001-2002 and 2012-2013. JAMA
Psychiatry, 72(12), 1235. doi:10.1001/jamapsychiatry.2015.1858.
Importance: Laws and attitudes toward marijuana in the United States are becoming more permissive but little
is known about whether the prevalence rates of marijuana use and marijuana use disorders have changed in the
21st century. Objective: To present nationally representative information on the past-year prevalence rates of
marijuana use, marijuana use disorder, and marijuana use disorder among marijuana users in the US adult
general population and whether this has changed between 2001-2002 and 2012-2013. Design, Setting, and
Participants: Face-to-face interviews conducted in surveys of 2 nationally representative samples of US adults:
the National Epidemiologic Survey on Alcohol and Related Conditions (data collected April 2001-April 2002;
N = 43,093) and the National Epidemiologic Survey on Alcohol and Related Conditions-III (data collected April
2012-June 2013; N = 36,309). Data were analyzed March through May 2015. Main Outcomes and Measures:
Past-year marijuana use and DSM-IV marijuana use disorder (abuse or dependence). Results: The past-year
prevalence of marijuana use was 4.1% (SE, 0.15) in 2001-2002 and 9.5% (SE, 0.27) in 2012-2013, a significant
increase (P < .05). Significant increases were also found across demographic subgroups (sex, age, race/ethnicity,
education, marital status, income, urban/rural, and region). The past-year prevalence of DSM-IV marijuana use
disorder was 1.5% (0.08) in 2001-2002 and 2.9% (SE, 0.13) in 2012-2013 (P < .05). With few exceptions, increases
in the prevalence of marijuana use disorder between 2001-2002 and 2012-2013 were also statistically significant
(P < .05) across demographic subgroups. However, the prevalence of marijuana use disorder among marijuana
users decreased significantly from 2001-2002 (35.6%; SE, 1.37) to 2012-2013 (30.6%; SE, 1.04). Conclusions:
The prevalence of marijuana use more than doubled between 2001-2002 and 2012-2013, and there was a large
increase in marijuana use disorders during that time. While not all marijuana users experience problems, nearly
3 of 10 marijuana users manifested a marijuana use disorder in 2012-2013. Because the risk for marijuana use
disorder did not increase among users, the increase in prevalence of marijuana use disorder is owing to an
increase in prevalence of users in the US adult population. Given changing laws and attitudes toward marijuana,
a balanced presentation of the likelihood of adverse consequences of marijuana use to policy makers,
professionals, and the public is needed.

36

 Lucas, P., Walsh, Z., Crosby, K., Callaway, R., Belle-Isle, L., Kay, R., . . . Holtzman, S. (2015). Substituting
Cannabis for Prescription Drugs, Alcohol and Other Substances Among Medical Cannabis Patients: The Impact
of Contextual Factors. Drug and Alcohol Review, 35(3), 326-333. doi:10.1111/dar.12323.
Introduction: Recent years have witnessed increased attention to how cannabis use impacts the use of other
psychoactive substances. The present study examines the use of cannabis as a substitute for alcohol, illicit
substances and prescription drugs among 473 adults who use cannabis for therapeutic purposes. Design and
Methods: The Cannabis Access for Medical Purposes Survey is a 414-question cross-sectional survey that was
available to Canadian medical cannabis patients online and by hard copy in 2011 and 2012 to gather information
on patient demographics, medical conditions and symptoms, patterns of medical cannabis use, cannabis
substitution and barriers to access to medical cannabis. Results: Substituting cannabis for one or more of
alcohol, illicit drugs or prescription drugs was reported by 87% (n = 410) of respondents, with 80.3% reporting
substitution for prescription drugs, 51.7% for alcohol, and 32.6% for illicit substances. Respondents who
reported substituting cannabis for prescription drugs were more likely to report difficulty affording sufficient
quantities of cannabis, and patients under 40 years of age were more likely to substitute cannabis for all three
classes of substance than older patients. Conclusions: The finding that cannabis was substituted for all three
classes of substances suggests that the medical use of cannabis may play a harm reduction role in the context of
use of these substances, and may have implications for abstinence-based substance use treatment approaches.
Further research should seek to differentiate between biomedical substitution for prescription pharmaceuticals
and psychoactive drug substitution, and to elucidate the mechanisms behind both.
Mark, K., & Terplan, M. (2017). Cannabis and pregnancy: Maternal Child Health Implications During a Period
of Drug Policy Liberalization. Preventive Medicine, 104, 46-49. doi:10.1016/j.ypmed.2017.05.012.
Abstract: Cannabis use is common and increasing among women in the United States. State policies are
changing with a movement towards decriminalization and legalization. We explore the implications of cannabis
liberalization for maternal and child health. Most women who use cannabis quit or cut back during pregnancy.
Although women are concerned about the possible health effects of cannabis, providers do a poor job of
counseling. There is a theoretical potential for cannabis to interfere with neurodevelopment, however human
data have not identified any long-term or long lasting meaningful differences between children exposed in utero
to cannabis and those not. Scientifically accurate dissemination of cannabis outcomes data is necessary. Risks
should be neither overstated nor minimized, and the legal status of a substance should not be equated with
safety. Decreasing or stopping use of all recreational drugs should be encouraged during pregnancy. Providers
must recognize that even in environments where cannabis is legal, pregnant women may end up involved with
Child Protective Services. In states where substance use is considered child abuse this may be especially
catastrophic. Above all, care for pregnant women who use cannabis should be non-punitive and grounded in
respect for patient autonomy.
Morris, M. A., Jacobson, S. R., Kinney, G. L., Tashkin, D. P., Woodruff, P. G., Hoffman, E. A., . . . Bowler, R. P.
(2018). Original Research Marijuana Use Associations with Pulmonary Symptoms and Function in Tobacco
Smokers Enrolled in The Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS).
Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, 5(1), 46-56. doi:10.15326/
jcopdf.5.1.2017.0141.
Background: Marijuana is often smoked via a filterless cigarette and contains similar chemical makeup as
smoked tobacco. There are few publications describing usage patterns and respiratory risks in older adults or in
those with chronic obstructive pulmonary disease (COPD). Methods: A cross-sectional analysis of current and

37

 former tobacco smokers from the Subpopulations and Intermediate Outcome Measures in COPD Study
(SPIROMICS) study assessed associations between marijuana use and pulmonary outcomes. Marijuana use was
defined as never, former (use over 30 days ago), or current (use within 30 days). Respiratory health was
assessed using quantitative high-resolution computed tomography (HRCT) scans, pulmonary function tests and
questionnaire responses about respiratory symptoms. Results: Of the total 2304 participants, 1130 (49%) never,
982 (43%) former, and 192 (8%) current marijuana users were included. Neither current nor former marijuana
use was associated with increased odds of wheeze (odds ratio [OR] 0.87, OR 0.97), cough (OR 1.22; OR 0.93) or
chronic bronchitis (OR 0.87; OR 1.00) when compared to never users. Current and former marijuana users had
lower quantitative emphysema (P=0.004, P=0.03), higher percent predicted forced expiratory volume in 1
second (FEV1%) (P<0.001, P<0.001), and percent predicted forced vital capacity (FVC%) (p<0.001, P<0.001).
Current marijuana users exhibited higher total tissue volume (P=0.003) while former users had higher air
trapping (P<0.001) when compared to never marijuana users. Conclusions: Marijuana use was found to have
little to no association with poor pulmonary health in older current and former tobacco smokers after adjusting
for covariates. Higher forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) was observed
among current marijuana users. However, higher joint years was associated with more chronic bronchitis
symptoms (e.g., wheeze), and this study cannot determine if long-term heavy marijuana smoking in the absence
of tobacco smoking is associated with lung symptoms, airflow obstruction, or emphysema, particularly in those
who have never smoked tobacco cigarettes.
Pletcher, M. J., Vittinghoff, E., Kalhan, R., Richman, J., Safford, M., Sidney, S., . . . Kertesz, S. (2012).
Association Between Marijuana Exposure and Pulmonary Function Over 20 Years. Jama, 307(2), 173.
doi:10.1001/jama.2011.1961.
Abstract: Marijuana smoke contains many of the same constituents as tobacco smoke, but whether it has
similar adverse effects on pulmonary function is unclear. Objective: To analyze associations between marijuana
(both current and lifetime exposure) and pulmonary function. Design: The Coronary Artery Risk Development
in Young Adults (CARDIA) study, a longitudinal study collecting repeated measurements of pulmonary function
and smoking over 20 years (March 26, 1985-August 19, 2006) in a cohort of 5115 men and women in 4 US cities.
Mixed linear modeling was used to account for individual age-based trajectories of pulmonary function and
other covariates including tobacco use, which was analyzed in parallel as a positive control. Lifetime exposure to
marijuana joints was expressed in joint-years, with 1 joint-year of exposure equivalent to smoking 365 joints or
filled pipe bowls. Main Outcome: Forced expiratory volume in the first second of expiration (FEV(1)) and forced
vital capacity (FVC). Results: Marijuana exposure was nearly as common as tobacco exposure but was mostly
light (median, 2-3 episodes per month). Tobacco exposure, both current and lifetime, was linearly associated
with lower FEV(1) and FVC. In contrast, the association between marijuana exposure and pulmonary function
was nonlinear (P < .001): at low levels of exposure, FEV(1) increased by 13 mL/joint-year (95% CI, 6.4 to 20; P <
.001) and FVC by 20 mL/joint-year (95% CI, 12 to 27; P < .001), but at higher levels of exposure, these
associations leveled or even reversed. The slope for FEV(1) was -2.2 mL/joint-year (95% CI, -4.6 to 0.3; P = .08) at
more than 10 joint-years and -3.2 mL per marijuana smoking episode/mo (95% CI, -5.8 to -0.6; P = .02) at more
than 20 episodes/mo. With very heavy marijuana use, the net association with FEV(1) was not significantly
different from baseline, and the net association with FVC remained significantly greater than baseline (eg, at 20
joint-years, 76 mL [95% CI, 34 to 117]; P < .001). Conclusion: Occasional and low cumulative marijuana use was
not associated with adverse effects on pulmonary function.
Powell, D., Pacula, R. L., & Jacobson, M. (2018). Do Medical Marijuana Laws Reduce Addictions and Deaths
Related to Pain Killers? Journal of Health Economics, 58, 29-42. doi:10.1016/j.jhealeco.2017.12.007.

38

 Abstract: Recent work finds that medical marijuana laws reduce the daily doses filled for opioid analgesics
among Medicare Part-D and Medicaid enrollees, as well as population-wide opioid overdose deaths. We
replicate the result for opioid overdose deaths and explore the potential mechanism. The key feature of a
medical marijuana law that facilitates a reduction in overdose death rates is a relatively liberal allowance for
dispensaries. As states have become more stringent in their regulation of dispensaries, the protective value
generally has fallen. These findings suggest that broader access to medical marijuana facilitates substitution of
marijuana for powerful and addictive opioids.
Russell, C., Rueda, S., Room, R., Tyndall, M., & Fischer, B. (2018). Routes of Administration for Cannabis Use –
Basic Prevalence and Related Health Outcomes: A Scoping Review and Synthesis. International Journal of
Drug Policy, 52, 87-96. doi:10.1016/j.drugpo.2017.11.008.
Background: Cannabis use is common, and associated with adverse health outcomes. 'Routes of administration'
(ROAs) for cannabis use have increasingly diversified, in part influenced by developments towards legalization.
This paper sought to review data on prevalence and health outcomes associated with different ROAs. Methods:
This scoping review followed a structured approach. Electronic searches for English-language peer-reviewed
publications were conducted in primary databases (i.e., MEDLINE, EMBASE, PsycINFO, Google Scholar) based on
pertinent keywords. Studies were included if they contained information on prevalence and/or health outcomes
related to cannabis use ROAs. Relevant data were screened, extracted and narratively summarized under
distinct ROA categories. Results: Overall, there is a paucity of rigorous and high-quality data on health outcomes
from cannabis ROAs, especially in direct and quantifiable comparison. Most data exist on smoking combusted
cannabis, which is associated with various adverse respiratory system outcomes (e.g., bronchitis, lung function).
Vaporizing natural cannabis and ingesting edibles appear to reduce respiratory system problems, but may come
with other risks (e.g., delayed impairment, use 'normalization'). Vaporizing cannabis concentrates can result in
distinct acute risks (e.g., excessive impairment, injuries). Other ROAs are uncommon and under-researched.
Conclusions: ROAs appear to distinctly influence health outcomes from cannabis use, yet systematic data for
comparative assessments are largely lacking; these evidence gaps require filling. Especially in emerging
legalization regimes, ROAs should be subject to evidence-based regulation towards improved public health
outcomes. Concretely, vaporizers and edibles may offer potential for reduced health risks, especially concerning
respiratory problems. Adequate cannabis product regulation (e.g., purity, labeling, THC-restrictions) is required
to complement ROA-based effects.
Rotermann, M., & Macdonald, R. (2018). Analysis of Trends in the Prevalence of Cannabis Use in Canada, 1985
to 2015. Health Reports, 29(2), 10-20.
Background: The Canadian federal government has committed to legalize, regulate, and restrict non-medical
cannabis use by adults in 2018. To prepare for monitoring the health, social and economic impacts of this policy
change, a greater understanding of the long-term trends in the prevalence of cannabis use in Canada is needed.
Methods: Nine national surveys of the household population collected information about cannabis use during
the period from 1985 through 2015. These surveys are examined for comparability. The data are used to
estimate past-year (current) cannabis use (total, and by sex and age). Based on the most comparable data,
trends in use from 2004 through 2015 are estimated. Results: From 1985 through 2015, past-year cannabis use
increased overall. Analysis of comparable data from the Canadian Tobacco Use Monitoring Survey and the
Canadian Tobacco, Alcohol and Drugs Survey for the 2004-to-2015 period suggests that use was stable among
15- to 17-year-old males, decreased among 15- to 17-year-old females and among 18- to 24-year-olds (both
sexes), and increased among people aged 25 or older. Discussion: According to data from national population
surveys, since 2004, cannabis use was stable or decreased among youth, and rose among adults. Results
highlight the importance of consistent monitoring of use in the pre-and post-legalization periods.

39

 Sohler, N. L., Starrels, J. L., Khalid, L., Bachhuber, M. A., Arnsten, J. H., Nahvi, S., . . . Cunningham, C. O. (2018).
Cannabis Use is Associated with Lower Odds of Prescription Opioid Analgesic Use Among HIV-Infected
Individuals with Chronic Pain. Substance Use & Misuse, 1-6. doi:10.1080/10826084.2017.1416408.
Background: Chronic pain is common in the United States and prescribed opioid analgesics use for noncancer
pain has increased dramatically in the past two decades, possibly accounting for the current opioid addiction
epidemic. Co-morbid drug use in those prescribed opioid analgesics is common, but there are few data on
polysubstance use patterns. Objective: We explored patterns of use of cigarette, alcohol, and illicit drugs in HIVinfected people with chronic pain who were prescribed opioid analgesics. Methods: We conducted a secondary
data analysis of screening interviews conducted as part of a parent randomized trial of financial incentives to
improve HIV outcomes among drug users. In a convenience sample of people with HIV and chronic pain, we
collected self-report data on demographic characteristics; pain; patterns of opioid analgesic use (both prescribed
and illicit); cigarette, alcohol, and illicit drug use (including cannabis, heroin, and cocaine) within the past 30
days; and current treatment for drug use and HIV. Results: Almost half of the sample of people with HIV and
chronic pain reported current prescribed opioid analgesic use (N = 372, 47.1%). Illicit drug use was common (N =
505, 63.9%), and cannabis was the most commonly used illicit substance (N = 311, 39.4%). In multivariate
analyses, only cannabis use was significantly associated with lower odds of prescribed opioid analgesic use
(adjusted odds ratio = 0.57; 95% confidence interval: 0.38-0.87). Conclusions/Importance: Our data suggest that
new medical cannabis legislation might reduce the need for opioid analgesics for pain management, which could
help to address adverse events associated with opioid analgesic use.
Stogner, J. M., & Miller, B. L. (2015). Assessing the Dangers of "Dabbing": Mere Marijuana or Harmful New
Trend? Pediatrics, 136(1), 1-3. doi:10.1542/peds.2015-0454.
The practice now known as “dabbing” appears to be quickly proliferating as a fashionable way to use marijuana
in the United States. Dabbing is the inhalation of a concentrated tetrahydrocannabinol (THC) product created
through butane extraction. The use of butane hash oil (BHO) products and the modification of cannabis more
generally are not new phenomena, but dabbing has recently moved from relative obscurity to the headlines,
leaving cannabis aficionados, adolescents, and parents curious about its effects. Physicians and other health
care professionals need to be prepared for discussions about the effects of dabbing to minimize potential harms,
particularly because recent marijuana policy changes likely have facilitated youth access to “dabs”.
Tarter, R. (2006). Predictors of Marijuana Use in Adolescents Before and After Licit Drug Use: Examination of
the Gateway Hypothesis. American Journal of Psychiatry, 163(12), 2134. doi:10.1176/appi.ajp.163.12.2134.
Objective: The authors investigated whether the transition from licit drug use to marijuana use is determined by
particular risk factors, as specified by the gateway hypothesis. They also evaluated the accuracy of the "gateway
sequence" (illicit drug use following licit drugs) for predicting a diagnosis of substance use disorder. Method:
Boys who consumed licit drugs only (N=99), boys who consumed licit drugs and then transitioned to marijuana
use (gateway sequence) (N=97), and boys who used marijuana before using licit substances (alternative
sequence) (N=28) were prospectively studied from ages 10-12 years through 22 years to determine whether
specific factors were associated with each drug use pattern. The groups were compared on 35 variables
measuring psychological, family, peer, school, and neighborhood characteristics. In addition, the utility of the
gateway and alternative sequences in predicting substance use disorder was compared to assess their clinical
informativeness. Results: Twenty-eight (22.4%) of the participants who used marijuana did not exhibit the
gateway sequence, thereby demonstrating that this pattern is not invariant in drug-using youths. Among youths
who did exhibit the gateway pattern, only delinquency was more strongly related to marijuana use than licit
drug use. Specific risk factors associated with transition from licit to illicit drugs were not revealed. The

40

 alternative sequence had the same accuracy for predicting substance use disorder as the gateway sequence.
Conclusions: Proneness to deviancy and drug availability in the neighborhood promote marijuana use. These
findings support the common liability model of substance use behavior and substance use disorder.
Volkow, N. D., Baler, R. D., Compton, W. M., & Weiss, S. R. (2014). Adverse Health Effects of Marijuana Use.
New England Journal of Medicine, 370(23), 2219-2227. doi:10.1056/ nejmra1402309.
In light of the rapidly shifting landscape regarding the legalization of marijuana for medical and recreational
purposes, patients may be more likely to ask physicians about its potential adverse and beneficial effects on
health. The popular notion seems to be that marijuana is a harmless pleasure, access to which should not be
regulated or considered illegal. Currently, marijuana is the most commonly used “illicit” drug in the United
States, with about 12% of people 12 years of age or older reporting use in the past year and particularly high
rates of use among young people. The most common route of administration is inhalation. The greenish-gray
shredded leaves and flowers of the Cannabis sativa plant are smoked (along with stems and seeds) in cigarettes,
cigars, pipes, water pipes, or “blunts” (marijuana rolled in the tobacco-leaf wrapper from a cigar). Hashish is a
related product created from the resin of marijuana flowers and is usually smoked (by itself or in a mixture with
tobacco) but can be ingested orally. Marijuana can also be used to brew tea, and its oil-based extract can be
mixed into food products.
Vyas, M. B., Lebaron, V. T., & Gilson, A. M. (2018). The Use of Cannabis in Response to the Opioid Crisis: A
Review of the Literature. Nursing Outlook, 66(1), 56-65. doi:10.1016/ j.outlook.2017.08.012.
Background: A staggering number of Americans are dying from overdoses attributed to prescription opioid
medications (POMs). In response, states are creating policies related to POM harm reduction strategies,
overdose prevention, and alternative therapies for pain management, such as cannabis (medical marijuana).
However, little is known about how the use of cannabis for pain management may be associated with POM use.
Purpose: The purpose of this article is to examine state medical cannabis (MC) use laws and policies and their
potential association with POM use and related harms. Methods: A systematic literature review was conducted
to explore United States policies related to MC use and the association with POM use and related harms.
Medline, PubMed, CINAHL, and Cochrane databases were searched to identify peer-reviewed articles published
between 2010 and 2017. Using the search criteria, 11,513 records were identified, with 789 abstracts reviewed,
and then 134 full-text articles screened for eligibility. Findings: Of 134 articles, 10 articles met inclusion criteria.
Four articles were cross-sectional online survey studies of MC substitution for POM, six were secondary data
analyses exploring state-level POM overdose fatalities, hospitalizations related to MC or POM harms, opioid use
disorder admissions, motor vehicle fatalities, and Medicare and Medicaid prescription cost analyses. The
literature suggests MC laws could be associated with decreased POM use, fewer POM-related hospitalizations,
lower rates of opioid overdose, and reduced national health care expenditures related to POM overdose and
misuse. However, available literature on the topic is sparse and has notable limitations. Conclusions: Review of
the current literature suggests states that implement MC policies could reduce POM-associated mortality,
improve pain management, and significantly reduce health care costs. However, MC research is constrained by
federal policy restrictions, and more research related to MC as a potential alternative to POM for pain
management, MC harms, and its impact on POM-related harms and health care costs should be a priority of
public health, medical, and nursing research.
Wang, G. S., Hall, K., Vigil, D., Banerji, S., Monte, A., & Vandyke, M. (2017). Marijuana and Acute Health Care
Contacts in Colorado. Preventive Medicine, 104, 24-30. doi:10.1016/j.ypmed.2017.03.022.

41

 Abstract: Over 22 million Americans are current users of marijuana; half of US states allow medical marijuana,
and several allow recreational marijuana. The objective of this study was to evaluate the impact marijuana has
on hospitalizations, emergency department (ED) visits, and regional poison center (RPC) calls in Colorado, a
medical and recreational marijuana state. This is a retrospective review using Colorado Hospital Association
hospitalizations and ED visits with marijuana-related billing codes, and RPC marijuana exposure calls.
Legalization of marijuana in Colorado has been associated with an increase in hospitalizations, ED visits, and RPC
calls linked with marijuana exposure. From 2000 to 2015, hospitalization rates with marijuana-related billing
codes increased from 274 to 593 per 100,000 hospitalizations in 2015. Overall, the prevalence of mental illness
among ED visits with marijuana-related codes was five-fold higher (5.07, 95% CI: 5.0, 5.1) than the prevalence of
mental illness without marijuana-related codes. RPC calls remained constant from 2000 through 2009. However,
in 2010, after local medical marijuana policy liberalization, the number of marijuana exposure calls significantly
increased from 42 to 93; in 2014, after recreational legalization, calls significantly increased by 79.7%, from 123
to 221 (p<0.0001). The age group <17years old also had an increase in calls after 2014. As more states legalize
marijuana, it is important to address public education and youth prevention, and understand the impact on
mental health disorders. Improvements in data collection and surveillance methods are needed to more
accurately evaluate the public health impact of marijuana legalization.
Wang, G. S., Roosevelt, G., Lait, M. L., Martinez, E. M., Bucher-Bartelson, B., Bronstein, A. C., & Heard, K.
(2014). Association of Unintentional Pediatric Exposures with Decriminalization of Marijuana in the United
States. Annals of Emergency Medicine, 63(6), 684-689. doi:10.1016/j.annemergmed.2014.01.017.
Objective: We compare state trends in unintentional pediatric marijuana exposures, as measured by call
volume to US poison centers, by state marijuana legislation status. Methods: A retrospective review of the
American Association of Poison Control Centers National Poison Data System was performed from January 1,
2005, to December 31, 2011. States were classified as nonlegal if they have not passed legislation, transitional if
they enacted legislation between 2005 and 2011, and decriminalized if laws passed before 2005. Our
hypotheses were that decriminalized and transitional states would experience a significant increase in call
volume, with more symptomatic exposures and more health care admissions than nonlegal states. Results:
There were 985 unintentional marijuana exposures reported from 2005 through 2011 in children aged 9 years
and younger: 496 in nonlegal states, 93 in transitional states, and 396 in decriminalized states. There was a slight
male predominance, and the median age ranged from 1.5 to 2.0 years. Clinical effects varied, with neurologic
effects the most frequent. More exposures in decriminalized states required health care evaluation and had
moderate to major clinical effects and critical care admissions compared with exposures from nonlegal states.
The call rate in nonlegal states to poison centers did not change from 2005 to 2011. The call rate in
decriminalized states increased by 30.3% calls per year, and transitional states had a trend toward an increase of
11.5% per year. Conclusion: Although the number of pediatric exposures to marijuana reported to the National
Poison Data System was low, the rate of exposure increased from 2005 to 2011 in states that had passed
marijuana legislation.
Wen, H., & Hockenberry, J. M. (2018). Association of Medical and Adult-Use Marijuana Laws with Opioid
Prescribing for Medicaid Enrollees. JAMA Internal Medicine. doi:10.1001/jamainternmed.2018.1007.
Importance: Overprescribing of opioids is considered a major driving force behind the opioid epidemic in the
United States. Marijuana is one of the potential nonopioid alternatives that can relieve pain at a relatively lower
risk of addiction and virtually no risk of overdose. Marijuana liberalization, including medical and adult-use
marijuana laws, has made marijuana available to more Americans. Objective: To examine the association of
state implementation of medical and adult-use marijuana laws with opioid prescribing rates and spending
among Medicaid enrollees. Design, Setting, and Participants: This cross-sectional study used a quasi-

42

 experimental difference-in-differences design comparing opioid prescribing trends between states that started
to implement medical and adult-use marijuana laws between 2011 and 2016 and the remaining states. This
population-based study across the United States included all Medicaid fee-for-service and managed care
enrollees, a high-risk population for chronic pain, opioid use disorder, and opioid overdose. Exposures: State
implementation of medical and adult-use marijuana laws from 2011 to 2016. Main Outcomes and Measures:
Opioid prescribing rate, measured as the number of opioid prescriptions covered by Medicaid on a quarterly,
per-1000-Medicaid-enrollee basis. Results: State implementation of medical marijuana laws was associated
with a 5.88% lower rate of opioid prescribing (95% CI, -11.55% to approximately -0.21%). Moreover, the
implementation of adult-use marijuana laws, which all occurred in states with existing medical marijuana laws,
was associated with a 6.38% lower rate of opioid prescribing (95% CI, -12.20% to approximately -0.56%).
Conclusions and Relevance: The potential of marijuana liberalization to reduce the use and consequences of
prescription opioids among Medicaid enrollees deserves consideration during the policy discussions about
marijuana reform and the opioid epidemic.
Zhu, H., & Wu, L. (2017). Sex Differences in Cannabis Use Disorder Diagnosis Involved Hospitalizations in the
United States. Journal of Addiction Medicine, 11(5), 357-367. doi:10.1097/adm.0000000000000330.
Objectives: The study examined sex differences in trend and clinical characteristics of cannabis use disorder
(CUD) diagnosis involved hospitalizations among adult patients. Methods: We analyzed hospitalization data
from the 2007-2011 Nationwide Inpatient Samples for patients aged 18-64 years (N = 15,114,930). Descriptive
statistics were used to characterize demographic variables and to compare the proportions of CUD diagnosis
and comorbid patterns between male and female hospitalizations. Logistic regressions were performed to
examine the association of sex and other demographic variables with CUD diagnosis. Results: During the study
period, 3.3% of male and 1.5% of female hospitalizations had any-listed CUD diagnoses, and both sexes
presented an upward trend in the number, rate, and proportion of CUD diagnosis. Among hospitalizations for
patients aged 18-25 years, about 1 in 10 males and 1 in 20 females included a CUD diagnosis, and this
proportion decreased with age strata. Mental disorders accounted for the highest proportion of CUD involved
inpatient hospitalizations, and female CUD involved hospitalizations included a higher proportion of mental
disorders that required hospitalized care compared with male hospitalizations (41% vs 36%). In each sex group,
younger age, black race, lower household income, large metropolitan residence, non-private insurance,
substance use diagnosis, and mental disorders were associated with elevated odds of having CUD diagnosis.
Conclusion: The large sample of clinical hospitalization data suggest an increased trend in CUD diagnosis and
sex differences in several comorbidities with CUD-involved hospital admissions. Prevention and treatment for
CUD should consider sex differences in clinical comorbidities.

Criminal Justice and Public Safety
Aston, E. R., Merrill, J. E., Mccarthy, D. M., & Metrik, J. (2016). Risk Factors for Driving After and During
Marijuana Use. Journal of Studies on Alcohol and Drugs, 77(2), 309-316. doi:10.15288/jsad.2016.77.309.
Objective: Use of marijuana before or while driving significantly contributes to driving impairment and elevated
risk of motor vehicle accidents; however, this risk behavior is common among users. Little is known about the
etiology of driving while under the influence of marijuana. Method: Guided by social learning theory, this study
examined marijuana outcome expectancies and other driving-related cognitions as predictors of the frequency
of driving after smoking marijuana (DASM) and smoking marijuana while driving (SMWD). A community sample
of 151 (64% male) non-treatment-seeking frequent marijuana users completed questionnaires on variables of
interest. Results: Perceived driving-related peer norms (i.e., perception that fewer friends disapprove of DASM

43

 and SMWD and of riding with a driver under the influence of marijuana) were associated with lower frequency
of both DASM and SMWD. Perceived dangerousness of DASM was also associated with decreased frequency of
DASM. Conclusions: Our findings suggest a range of potentially important targets for interventions intended to
reduce the likelihood and frequency of driving while under the influence of marijuana.
Aydelotte, J. D., Brown, L. H., Luftman, K. M., Mardock, A. L., Teixeira, P. G., Coopwood, B., & Brown, C. V.
(2017). Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado. American
Journal of Public Health, 107(8), 1329-1331. doi:10.2105/ajph.2017.303848.
Objectives: To evaluate motor vehicle crash fatality rates in the first 2 states with recreational marijuana
legalization and compare them with motor vehicle crash fatality rates in similar states without recreational
marijuana legalization. Methods: We used the US Fatality Analysis Reporting System to determine the annual
numbers of motor vehicle crash fatalities between 2009 and 2015 in Washington, Colorado, and 8 control states.
We compared year-over-year changes in motor vehicle crash fatality rates (per billion vehicle miles traveled)
before and after recreational marijuana legalization with a difference-in-differences approach that controlled for
underlying time trends and state-specific population, economic, and traffic characteristics. RESULTS: Prerecreational marijuana legalization annual changes in motor vehicle crash fatality rates for Washington and
Colorado were similar to those for the control states. Post-recreational marijuana legalization changes in motor
vehicle crash fatality rates for Washington and Colorado also did not significantly differ from those for the
control states (adjusted difference-in-differences coefficient = +0.2 fatalities/billion vehicle miles traveled; 95%
confidence interval = -0.4, +0.9). Conclusions: Three years after recreational marijuana legalization, changes in
motor vehicle crash fatality rates for Washington and Colorado were not statistically different from those in
similar states without recreational marijuana legalization. Future studies over a longer time remain warranted.
Doucette, M. L., Frattaroli, S., & Vernick, J. S. (2017). Oral Fluid Testing for Marijuana Intoxication: Enhancing
Objectivity for Roadside DUI Testing. Injury Prevention, 24(1), 78-80. doi:10.1136/injuryprev-2016-042264.
Abstract: Reducing marijuana-impaired driving is an important part of any strategy to prevent motor vehicle
traffic injuries. In Colorado, the first of eight US states and the District of Columbia to legalise marijuana for
recreational use, drivers with positive tests for the presence of marijuana accounted for a larger proportion of
fatal MVCs after marijuana commercialisation. The use of blood tests to screen for marijuana intoxication, in
Colorado and elsewhere in the USA, poses a number of challenges. Many high-income countries use oral fluid
drug testing (OF) to provide roadside evidence of marijuana intoxication. A 2009 Belgium policy implementing
OF roadside testing increased true positives and decreased false positives of suspected marijuana-related driving
under the influence (DUI) arrests. US policy-makers should consider using roadside OF to increase objectivity
and reliability for tests used in marijuana-related DUI arrests.
Freisthler, B., Gaidus, A., Tam, C., Ponicki, W. R., & Gruenewald, P. J. (2017). From Medical to Recreational
Marijuana Sales: Marijuana Outlets and Crime in an Era of Changing Marijuana Legislation. The Journal of
Primary Prevention, 38(3), 249-263. doi:10.1007/s10935-017-0472-9.
Abstract: A movement from medical to recreational marijuana use allows for a larger base of potential users
who have easier access to marijuana, because they do not have to visit a physician before using marijuana. This
study examines whether changes in the density of marijuana outlets were related to violent, property, and
marijuana-specific crimes in Denver, CO during a time in which marijuana outlets began selling marijuana for
recreational, and not just medical, use. We collected data on locations of crimes, marijuana outlets and
covariates for 481 Census block groups over 34 months (N = 16,354 space-time units). A Bayesian Poisson spacetime model assessed statistical relationships between independent measures and crime counts within "local"

44

 Census block groups. We examined spatial "lag" effects to assess whether crimes in Census block groups
adjacent to locations of outlets were also affected. Independent of the effects of covariates, densities of
marijuana outlets were unrelated to property and violent crimes in local areas. However, the density of
marijuana outlets in spatially adjacent areas was positively related to property crime in spatially adjacent areas
over time. Further, the density of marijuana outlets in local and spatially adjacent blocks groups was related to
higher rates of marijuana-specific crime. This study suggests that the effects of the availability of marijuana
outlets on crime do not necessarily occur within the specific areas within which these outlets are located, but
may occur in adjacent areas. Thus studies assessing the effects of these outlets in local areas alone may risk
underestimating their true effects.
Jin, H., Williams, S. Z., Chihuri, S. T., Li, G., & Chen, Q. (2018). Validity of Oral Fluid Test for Delta-9tetrahydrocannabinol in Drivers Using the 2013 National Roadside Survey Data. Injury Epidemiology, 5(1).
doi:10.1186/s40621-018-0134-2.
Background: Driving under the influence of marijuana is a serious traffic safety concern in the United States.
Delta 9-tetrahydrocannabinol (THC) is the main active compound in marijuana. Although blood THC testing is a
more accurate measure of THC-induced impairment, measuring THC in oral fluid is a less intrusive and less costly
method of testing. Methods: We examined whether the oral fluid THC test can be used as a valid alternative to
the blood THC test using a sensitivity and specificity analysis and a logistic regression, and estimate the
quantitative relationship between oral fluid THC concentration and blood THC concentration using a correlation
analysis and a linear regression on the log-transformed THC concentrations. We used data from 4596 drivers
who participated in the 2013 National Roadside Survey of Alcohol and Drug Use by Drivers and for whom THC
testing results from both oral fluid and whole blood samples were available. Results: Overall, 8.9% and 9.4% of
the participants tested positive for THC in oral fluid and whole blood samples, respectively. Using blood test as
the reference criterion, oral fluid test for THC positivity showed a sensitivity of 79.4% (95% CI: 75.2%, 83.1%) and
a specificity of 98.3% (95% CI: 97.9%, 98.7%). The log-transformed oral fluid THC concentration accounted for
about 29% of the variation in the log-transformed blood THC concentration. That is, there is still 71% of the
variation in the log-transformed blood THC concentration unexplained by the log-transformed oral fluid THC
concentration. Back-transforming to the original scale, we estimated that each 10% increase in the oral fluid THC
concentration was associated with a 2.4% (95% CI: 2.1%, 2.8%) increase in the blood THC concentration.
Conclusions: The oral fluid test is a highly valid method for detecting the presence of THC in the blood but
cannot be used to accurately measure the blood THC concentration.
Johnson, B. D., Ream, G. L., Dunlap, E., & Sifaneck, S. J. (2008). Civic Norms and Etiquettes Regarding
Marijuana Use in Public Settings in New York City. Substance Use & Misuse, 43(7), 895-918.
doi:10.1080/10826080701801477.
Abstract: This paper shows that active police enforcement of civic norms against marijuana smoking in public
settings has influenced the locations where marijuana is smoked. It has subtly influenced the various marijuana
etiquettes observed in both public and private settings. The ethnographic data reveal the importance of
informal sanctions; most marijuana consumers report compliance with etiquettes mainly to avoid stigma from
nonusing family, friends, and associates-they express limited concern about police and arrest.
Urfer, S., Morton, J., Beall, V., Feldmann, J., & Gunesch, J. (2014). Analysis of Δ9-tetrahydrocannabinol Driving
Under the Influence of Drugs Cases in Colorado from January 2011 to February 2014. Journal of Analytical
Toxicology, 38(8), 575-581. doi:10.1093/jat/bku089.

45

 Abstract: Driving under the influence (DUI) and DUI drugs (DUID) law enforcement (LE) cases (n = 12,082) where
whole blood samples were submitted to ChemaTox Laboratory, Inc. in Boulder, CO, for testing were examined.
Of these 12,082 cases, there were 4,235 cannabinoid screens (CS) requested. Samples that yielded a positive CS
(n = 2,621) were further analyzed. A total of 1,848 samples were confirmed for Δ9-tetrahydrocannabinol (THC)
after a positive CS. Due to a decrease in the confirmation limit of detection (LOD) for THC from 2 to 1 ng/mL,
samples that were confirmed for THC and quantitated below 2 ng/mL (n = 250) were considered negative. After
this normalization, there were 1,598 samples that were confirmed positive for THC and included in the analysis.
The percentage of LE cases with requests for CS for all years was 35%, increasing from 28% in 2011 to 37% in
2013. The positivity rate of CS overall was 62% (range: 59-68% by year) with no significant change over the time
frame examined. The percentage of positive CS in which THC was confirmed positive at or above 2 ng/mL (n =
1,598) increased significantly from 28% in 2011 to 65% in 2013. The mean and median THC concentrations were
8.1 and 6.3 ng/mL, respectively (range: 2-192 ng/mL, n = 1,367). The data presented illustrate a statistically
significant increase in CS that result in positive THC confirmations. Although the specific cause of this increase is
not known at this time, possible ties to ongoing developments in Colorado's marijuana legislation merit further
analysis.
Wong, K., Brady, J. E., & Li, G. (2014). Establishing Legal Limits for Driving Under the Influence of Marijuana.
Injury Epidemiology, 1(1). doi:10.1186/s40621-014-0026-z.
Abstract: Marijuana has become the most commonly detected non-alcohol substance among drivers in the
United States and Europe. Use of marijuana has been shown to impair driving performance and increase crash
risk. Due to the lack of standardization in assessing marijuana-induced impairment and limitations of zero
tolerance legislation, more jurisdictions are adopting per se laws by specifying a legal limit of Δ9tetrahydrocannabinol (THC) at or above which drivers are prosecuted for driving under the influence of
marijuana. This review examines major considerations when developing these threshold THC concentrations and
specifics of legal THC limits for drivers adopted by different jurisdictions in the United States and other
countries.

Economic
Aston, E. R., Metrik, J., & Mackillop, J. (2015). Further validation of a marijuana purchase task. Drug and
Alcohol Dependence, 152, 32-38. doi:10.1016/j.drugalcdep. 2015.04.025.
Background: A valid measure of the relative economic value of marijuana is needed to characterize individual
variation in the drug's reinforcing value and inform evolving national marijuana policy. Relative drug value
(demand) can be measured via purchase tasks, and demand for alcohol and cigarettes has been associated with
craving, dependence, and treatment response. This study examined marijuana demand with a marijuana
purchase task (MPT). Methods: The 22-item self-report MPT was administered to 99 frequent marijuana users
(37.4% female, 71.5% marijuana use days, 15.2% cannabis dependent). Results: Pearson correlations indicated a
negative relationship between intensity (free consumption) and age of initiation of regular use (r=-0.34,
p<0.001), and positive associations with use days (r=0.26, p<0.05) and subjective craving (r=0.43, p<0.001).
Omax (maximum expenditure) was positively associated with use days (r=0.29, p<0.01) and subjective craving
(r=0.27, p<0.01). Income was not associated with demand. An exponential demand model provided an excellent
fit to the data across users (R(2)=0.99). Group comparisons based on presence or absence of DSM-IV cannabis
dependence symptoms revealed that users with any dependence symptoms showed significantly higher
intensity of demand and more inelastic demand, reflecting greater insensitivity to price increases. Conclusions:
These results provide support for construct validity of the MPT, indicating its sensitivity to marijuana demand as

46

 a function of increasing cost, and its ability to differentiate between users with and without dependence
symptoms. The MPT may denote abuse liability and is a valuable addition to the behavioral economic literature.
Potential applications to marijuana pricing and tax policy are discussed.
Azofeifa, A., Sherman, L. J., Mattson, M. E., & Pacula, R. L. (2018). Marijuana buyers in the United States,
2010–2014. Drug and Alcohol Dependence, 183, 34-42. doi:10.1016/j.drugalcdep.2017.10.019.
Background: Obtaining or purchasing marijuana in the U.S. can be done only in certain states via a lawful
market for medical or non-medical (recreational) purposes, or via an unlawful market ("black market") by home
cultivation and unlicensed vendors and individuals. Given the evolving U.S. state marijuana legislation landscape,
the objective of this study is to describe individuals who report buying marijuana in the past year by selected
characteristics and U.S. geographical location. Methods: Using data from the 2010-2014 National Survey on
Drug Use and Health (NSDUH), we conducted bivariate chi-square tests to examine sociodemographic and
selected behavioral indicators associated with buying marijuana and analyzed these factors in a multivariable
logistic regression model. NSDUH participants were the noninstitutionalized civilian population aged 12+
(approximately 62,100 individuals per year) who reported using marijuana in the past year (approximately
12,400 annual average). Results: A weighted estimate of approximately 18.5 million individuals aged 12+
reported buying marijuana in the past year (59% of marijuana users). Overall, buyers of marijuana were more
likely to be male, report using marijuana for a greater number of days, and to meet the criteria for substance
use disorder and marijuana dependence. Data showed differences of proportion of marijuana buyers by state of
residence. Conclusions: Given recent changes in state laws and policies and the increased demand for
marijuana products, continued monitoring of the U.S. marijuana market in coming years is important in order to
understand consumption and buying patterns among at-risk segments of the population, especially youth.
Hunt, P., & Pacula, R. L. (2017). Early Impacts of Marijuana Legalization: An Evaluation of Prices in Colorado
and Washington. The Journal of Primary Prevention, 38(3), 221-248. doi:10.1007/s10935-017-0471-x.
Abstract: Following the legalization and regulation of marijuana for recreational purposes in states with medical
markets, policymakers and researchers seek empirical evidence on how, and how fast, supply and demand
changed over time. Prices are an indication of how suppliers and consumers respond to policy changes, so this
study uses a difference-in-difference approach to exploit the timing of policy implementation and identify the
impacts on marijuana prices 4-5 months after markets opened. This study uses unique longitudinal survey data
of prices paid by consumers and a web-scraped dataset of dispensary prices advertised online for three U.S.
medical marijuana states that all eventually legalized recreational marijuana. Results indicate there were no
impacts on the prices paid for medical or recreational marijuana by state-representative residents within the
short 4- to 5-months window following legalization. However, there were differences in how much people paid
if they obtained marijuana for recreational purposes from a recreational store. Further analysis of advertised
prices confirms this result, but further demonstrates heterogeneous responses in prices across types of
commonly advertised strains; prices either did not change or increased depending on the strain type. A key
implication of our findings is that there are both supply and demand responses at work in the opening of
legalized markets, suggesting that evaluations of immediate effects may not accurately reflect the long run
impact of legalization on consumption.
Jensen, E. L., & Roussell, A. (2016). Field observations of the developing legal recreational cannabis economy
in Washington State. International Journal of Drug Policy, 33, 96-101. doi:10.1016/j.drugpo.2016.02.023.
Background: Washington State legalized the sale of recreational cannabis in 2012. This paper describes the
unfolding of the market regulatory regime in an eastern portion of the state, including field descriptions to

47

 illustrate the setting. Methods: We made observations and conducted interviews of the local supply chain
comprising a producer/processor, analytic facility, and retail establishments as well as querying the state
director of the regulatory board. Results: Interviews and observations of facilities suggest an overwhelming
concern for black market diversion drives state regulatory efforts. The ongoing dialogue between market actors
and the state has resulted in a more equitable distribution of profits at different stages in the process. State
safety regulations have thus far been shifted to independent laboratories. Banks and insurance companies have
slowly begun making inroads into the industry, despite federal prohibition. Conclusion: The law was conceived
as a social justice remedy, but the bulk of the legal and regulatory activity surrounds cannabis marketplace
management. This has been characterized by concerns for black market diversion, producer/processor profits,
and a hands-off approach to safety regulation. Minor cannabis violations as a pathway to criminal justice system
involvement have been reduced substantially but disproportionate enforcement upon racial/ethnic minorities
continues.
Shanahan, M., & Ritter, A. (2014). Cost Benefit Analysis of Two Policy Options for Cannabis: Status Quo and
Legalisation. PLoS ONE, 9(4). doi:10.1371/ journal.pone.0095569.
Aims: To date there has been limited analysis of the economic costs and benefits associated with cannabis
legalisation. This study redresses this gap. A cost benefit analysis of two cannabis policy options the status quo
(where cannabis use is illegal) and a legalised–regulated option was conducted. Method: A cost benefit analysis
was used to value the costs and benefits of the two policies in monetary terms. Costs and benefits of each policy
option were classified into five categories (direct intervention costs, costs or cost savings to other agencies,
benefits or lost benefits to the individual or the family, other impacts on third parties, and adverse or spill over
events). The results are expressed as a net social benefit (NSB). Findings: The mean NSB per annum from Monte
Carlo simulations (with the 5 and 95 percentiles) for the status quo was $294.6 million AUD ($201.1 to $392.7
million) not substantially different from the $234.2 million AUD ($136.4 to $331.1 million) for the legalised–
regulated model which excludes government revenue as a benefit. When government revenue is included, the
NSB for legalised–regulated is higher than for status quo. Sensitivity analyses demonstrate the significant impact
of educational attainment and wellbeing as drivers for the NSB result. Conclusion: Examining the percentiles
around the two policy options, there appears to be no difference between the NSB for these two policy options.
Economic analyses are essential for good public policy, providing information about the extent to which one
policy is substantially economically favourable over another. In cannabis policy, for these two options this does
not appear to be the case.
Vincent, P. C., Collins, R. L., Liu, L., Yu, J., Leo, J. A., & Earleywine, M. (2017). The Effects of Perceived Quality
on Behavioral Economic Demand for Marijuana: A Web-Based Experiment. Drug and Alcohol Dependence,
170, 174-180. doi:10.1016/ j.drugalcdep.2016.11.013.
Background: Given the growing legalization of recreational marijuana use and related increase in its prevalence
in the United States, it is important to understand marijuana's appeal. We used a behavioral economic (BE)
approach to examine whether the reinforcing properties of marijuana, including "demand" for marijuana, varied
as a function of its perceived quality. Methods: Using an innovative, Web-based marijuana purchase task (MPT),
a sample of 683 young-adult recreational marijuana users made hypothetical purchases of marijuana across
three qualities (low, mid and high grade) at nine escalating prices per joint, ranging from $0/free to $20. Results:
We used nonlinear mixed effects modeling to conduct demand curve analyses, which produced separate
demand indices (e.g., Pmax, elasticity) for each grade of marijuana. Consistent with previous research, as the price
of marijuana increased, marijuana users reduced their purchasing. Demand also was sensitive to quality, with
users willing to pay more for higher quality/grade marijuana. In regression analyses, demand indices accounted
for significant variance in typical marijuana use. Conclusions: This study illustrates the value of applying BE

48

 theory to young adult marijuana use. It extends past research by examining how perceived quality affects
demand for marijuana and provides support for the validity of a Web-based MPT to examine the appeal of
marijuana. Our results have implications for policies to regulate marijuana use, including taxation based on the
quality of different marijuana products.

Education
Cerdá, M., Wall, M., Feng, T., Keyes, K. M., Sarvet, A., Schulenberg, J., . . . Hasin, D. S. (2017). Association of
State Recreational Marijuana Laws with Adolescent Marijuana Use. JAMA Pediatrics, 171(2), 142.
doi:10.1001/jamapediatrics.2016.3624.
Importance: Historical shifts are occurring in marijuana policy. The effect of legalizing marijuana for recreational
use on rates of adolescent marijuana use is a topic of considerable debate. Objective: To examine the
association between the legalization of recreational marijuana use in Washington and Colorado in 2012 and the
subsequent perceived harmfulness and use of marijuana by adolescents. Design: We used data of 253,902
students in eighth, 10th, and 12th grades from 2010 to 2015 from Monitoring the Future, a national, annual,
cross-sectional survey of students in secondary schools in the contiguous United States. Difference-in-difference
estimates compared changes in perceived harmfulness of marijuana use and in past-month marijuana use in
Washington and Colorado prior to recreational marijuana legalization (2010-2012) with post legalization (20132015) vs the contemporaneous trends in other states that did not legalize recreational marijuana use in this
period. Main Outcomes: Perceived harmfulness of marijuana use (great or moderate risk to health from
smoking marijuana occasionally) and marijuana use (past 30 days). Results: Of the 253,902 participants,
120,590 of 245,065(49.2%) were male, and the mean (SD) age was 15.6 (1.7) years. In Washington, perceived
harmfulness declined 14.2% and 16.1% among eighth and 10th graders, respectively, while marijuana use
increased 2.0% and 4.1% from 2010-2012 to 2013-2015. In contrast, among states that did not legalize
recreational marijuana use, perceived harmfulness decreased by 4.9% and 7.2% among eighth and 10th graders,
respectively, and marijuana use decreased by 1.3% and 0.9% over the same period. Difference-in-difference
estimates comparing Washington vs states that did not legalize recreational drug use indicated that these
differences were significant for perceived harmfulness (eighth graders: % [SD], -9.3 [3.5]; P = .01; 10th graders: %
[SD], -9.0 [3.8]; P = .02) and marijuana use (eighth graders: % [SD], 5.0 [1.9]; P = .03; 10th graders: % [SD], 3.2
[1.5]; P = .007). No significant differences were found in perceived harmfulness or marijuana use among 12th
graders in Washington or for any of the 3 grades in Colorado. Conclusions: Among eighth and 10th graders in
Washington, perceived harmfulness of marijuana use decreased and marijuana use increased following
legalization of recreational marijuana use. In contrast, Colorado did not exhibit any differential change in
perceived harmfulness or past-month adolescent marijuana use following legalization. A cautious interpretation
of the findings suggests investment in evidence-based adolescent substance use prevention programs in any
additional states that may legalize recreational marijuana use.
Fischer, B., Russell, C., Sabioni, P., Brink, W. V., Foll, B. L., Hall, W., . . . Room, R. (2017). Lower-Risk Cannabis
Use Guidelines: A Comprehensive Update of Evidence and Recommendations. American Journal of Public
Health, 107(8), 1277-1277. doi:10.2105/ ajph.2017.303818a.
Background: Cannabis use is common in North America, especially among young people, and is associated with
a risk of various acute and chronic adverse health outcomes. Cannabis control regimes are evolving, for example
toward a national legalization policy in Canada, with the aim to improve public health, and thus require
evidence-based interventions. As cannabis-related health outcomes may be influenced by behaviors that are
modifiable by the user, evidence-based Lower-Risk Cannabis Use Guidelines (LRCUG) — a kin to similar

49

 guidelines in other health fields – offer a valuable, targeted prevention tool to improve public health outcomes.
Objectives: To systematically review, update, and quality-grade evidence on behavioral factors determining
adverse health outcomes from cannabis that may be modifiable by the user, and translate this evidence into
revised LRCUG as a public health intervention tool based on an expert consensus process. Methods: We used
pertinent medical search terms and structured search strategies, to search MEDLINE, EMBASE, PsycINFO,
Cochrane Library databases, and reference lists primarily for systematic reviews and meta-analyses, and
additional evidence on modifiable risk factors for adverse health outcomes from cannabis use. Selection
Criteria: We included studies if they focused on potentially modifiable behavior-based factors for risks or harms
for health from cannabis use, and excluded studies if cannabis use was assessed for therapeutic purposes. Data
Collection and Analysis: We screened the titles and abstracts of all studies identified by the search strategy and
assessed the full texts of all potentially eligible studies for inclusion; 2 of the authors independently extracted
the data of all studies included in this review. We created Preferred Reporting Items for Systematic Reviews and
Meta-Analyses flow-charts for each of the topical searches. Subsequently, we summarized the evidence by
behavioral factor topic, quality-graded it by following standard (Grading of Recommendations Assessment,
Development, and Evaluation; GRADE) criteria, and translated it into the LRCUG recommendations by the author
expert collective on the basis of an iterative consensus process. Main Results: For most recommendations,
there was at least "substantial" (i.e., good-quality) evidence. We developed 10 major recommendations for
lower-risk use: (1) the most effective way to avoid cannabis use-related health risks is abstinence, (2) avoid early
age initiation of cannabis use (i.e., definitively before the age of 16 years), (3) choose low-potency
tetrahydrocannabinol (THC) or balanced THC-to-cannabidiol (CBD)-ratio cannabis products, (4) abstain from
using synthetic cannabinoids, (5) avoid combusted cannabis inhalation and give preference to nonsmoking use
methods, (6) avoid deep or other risky inhalation practices, (7) avoid high-frequency (e.g., daily or near-daily)
cannabis use, (8) abstain from cannabis-impaired driving, (9) populations at higher risk for cannabis use-related
health problems should avoid use altogether, and (10) avoid combining previously mentioned risk behaviors
(e.g., early initiation and high-frequency use). Conclusions: Evidence indicates that a substantial extent of the
risk of adverse health outcomes from cannabis use may be reduced by informed behavioral choices among
users. The evidence-based LRCUG serve as a population-level education and intervention tool to inform such
user choices toward improved public health outcomes. However, the LRCUG ought to be systematically
communicated and supported by key regulation measures (e.g., cannabis product labeling, content regulation)
to be effective. All of these measures are concretely possible under emerging legalization regimes, and should
be actively implemented by regulatory authorities. The population-level impact of the LRCUG toward reducing
cannabis use-related health risks should be evaluated. Public health implications: Cannabis control regimes are
evolving, including legalization in North America, with uncertain impacts on public health. Evidence-based
LRCUG offer a potentially valuable population-level tool to reduce the risk of adverse health outcomes from
cannabis use among (especially young) users in legalization contexts, and hence to contribute to improved
public health outcomes.
Ghosh, T. S., Dyke, M. V., Maffey, A., Whitley, E., Erpelding, D., & Wolk, L. (2015). Medical Marijuana’s Public
Health Lessons — Implications for Retail Marijuana in Colorado. New England Journal of Medicine, 372(11),
991-993. doi:10.1056/ nejmp1500043.
In 2000, Colorado residents voted to legalize marijuana use for medical conditions such as glaucoma, HIV/AIDS,
cancer, seizures, and severe pain. From 2000 to 2009, medical marijuana was available in Colorado only from
plants grown in noncommercial, home settings, and the number of medical users or registrants remained
relatively small. But in 2010, state law was changed to permit commercial production and distribution of
medical marijuana. The number of registrants (both adults and children) grew rapidly – from 4819 in December
2008 to 115,467 in December 2014 – and medical marijuana dispensaries proliferated. Then, on January 1,
2014, Colorado became the first U.S. state to allow sales of recreational, or retail, marijuana. With no state
models or national guidance to follow, Colorado public health officials have turned to lessons from medical

50

 marijuana to prepare for the potential public health implications of more widely available recreational
marijuana.
Ghosh, T., Dyke, M. V., Maffey, A., Whitley, E., Gillim-Ross, L., & Wolk, L. (2016). The Public Health Framework
of Legalized Marijuana in Colorado. American Journal of Public Health, 106(1), 21-27.
doi:10.2105/ajph.2015.302875.
On January 1, 2014, Colorado became the first state in the nation to sell legal recreational marijuana for adult
use. As a result, Colorado has had to carefully examine potential population health and safety impacts as well as
the role of public health in response to legalization. We have discussed an emerging public health framework for
legalized recreational marijuana. We have outlined this framework according to the core public health functions
of assessment, policy development, and assurance. In addition, we have discussed challenges to implement this
framework that other states considering legalization may face.
Ghosh, T. S., Vigil, D. I., Maffey, A., Tolliver, R., Dyke, M. V., Kattari, L., . . . Wolk, L. (2017). Lessons Learned
After Three Years of Legalized, Recreational Marijuana: The Colorado Experience. Preventive Medicine, 104, 46. doi:10.1016/j.ypmed. 2017.02.021.
Abstract: In November 2012, Colorado voters approved legalized recreational marijuana. On January 1, 2014,
Colorado became the first state to allow legal sales of non-medical marijuana for adults over the age of 21. Since
that time, the state has been monitoring potential impacts on population health. In this paper, we present
lessons learned in the first three years following legal sales of recreational marijuana. These lessons pertain to
health behaviors and health outcomes, as well as to health policy issues. Our intent is to share these lessons
with other states as they face the prospect of recreational marijuana legalization.
Hanson, K., Haggerty, K. P., Fleming, C. B., Skinner, M. L., Casey-Goldstein, M., Mason, W. A., . . . Redmond, C.
(2018). Washington State Retail Marijuana Legalization: Parent and Adolescent Preferences for Marijuana
Messages in a Sample of Low-Income Families. Journal of Studies on Alcohol and Drugs, 79(2), 309-317.
doi:10.15288/jsad.2018.79.309.
Objective: As legalization of nonmedical retail marijuana increases, states are implementing public health
campaigns designed to prevent increases in youth marijuana use. This study investigated which types of
marijuana-related messages were rated most highly by parents and their teens and whether these preferences
differed by age and marijuana use. Method: Nine marijuana-focused messages were developed as potential
radio, newspaper, or television announcements. The messages fell into four categories: information about the
law, general advice/conversation starters, consequences of marijuana use/positive alternatives, and information
on potential harmful effects of teen marijuana use. The messages were presented through an online survey to
282 parents (84% female) and 283 teen (54% female) participants in an ongoing study in Washington State.
Results: Both parents and youth rated messages containing information about the law higher than other types
of messages. Messages about potential harms of marijuana use were rated lower than other messages by both
generations. Parents who had used marijuana within the past year (n = 80) rated consequence/positive
alternative messages lower than parent nonusers (n = 199). Youth marijuana users (n = 77) and nonusers (n =
202) both rated messages containing information about the law higher than other types of messages. Youth
users and nonusers were less likely than parents to believe messages on the harmful effects of marijuana.
Conclusions: The high ratings for messages based on information about the marijuana law highlight the need for
informational health campaigns to be established as a first step in the marijuana legalization process.

51

 Harpin, S. B., Brooks-Russell, A., Ma, M., James, K. A., & Levinson, A. H. (2017). Adolescent Marijuana Use and
Perceived Ease of Access Before and After Recreational Marijuana Implementation in Colorado. Substance Use
& Misuse, 53(3), 451-456. doi:10.1080/ 10826084.2017.1334069.
Background: As of January 1, 2017, eight states have approved laws for recreational marijuana use. While the
social impacts of these changes remain under debate, the influence on adolescent marijuana use is a key policy
and health issue across the U.S. Objective: To examine changes in adolescent marijuana-use behaviors in the
first year after recreational marijuana implementation in Colorado, and to analyze the effect of retail marijuana
store proximity on youth use and perceptions. Method: Secondary analysis of Healthy Kids Colorado Survey
data from 40 schools surveyed before and after recreational marijuana sales were implemented (2013 student n
= 12,240; 2014 student n = 11,931). Self-reported marijuana use, ease of access, and perceived harms were
compared between years and by proximity of recreational marijuana stores to surveyed schools. Results:
Adolescent marijuana use behaviors, wrongness of use, and perceptions of risk of harm were unchanged from
baseline to one-year follow-up. Perceived ease of access to marijuana increased (from 46% to 52%). Proximity of
recreational marijuana stores was not significantly associated with perceived ease of access to marijuana.
Conclusions/Importance: In the first study of adolescent marijuana use and perceptions after state retail
implementation of recreational marijuana, there was little change in adolescent marijuana use but a significant
change in perception of ease of access. Public health workers and policymakers should continue to monitor
these changes as essential for evaluating the impact of liberalization of marijuana policies.
Hasin, D. S. (2017). US Epidemiology of Cannabis Use and Associated Problems. Neuropsychopharmacology,
43(1), 195-212. doi:10.1038/npp.2017.198.
Abstract: This review provides an overview of the changing US epidemiology of cannabis use and associated
problems. Adults and adolescents increasingly view cannabis as harmless, and some can use cannabis without
harm. However, potential problems include harms from prenatal exposure and unintentional childhood
exposure; decline in educational or occupational functioning after early adolescent use, and in adulthood,
impaired driving and vehicle crashes; cannabis use disorders (CUD), cannabis withdrawal, and psychiatric
comorbidity. Evidence suggests national increases in cannabis potency, prenatal and unintentional childhood
exposure; and in adults, increased use, CUD, cannabis-related emergency room visits, and fatal vehicle crashes.
Twenty-nine states have medical marijuana laws (MMLs) and of these, 8 have recreational marijuana laws
(RMLs). Many studies indicate that MMLs or their specific provisions did not increase adolescent cannabis use.
However, the more limited literature suggests that MMLs have led to increased cannabis potency, unintentional
childhood exposures, adult cannabis use, and adult CUD. Ecological-level studies suggest that MMLs have led to
substitution of cannabis for opioids, and also possibly for psychiatric medications. Much remains to be
determined about cannabis trends and the role of MMLs and RMLs in these trends. The public, health
professionals, and policy makers would benefit from education about the risks of cannabis use, the increases in
such risks, and the role of marijuana laws in these increases.
Maggs, J. L., Staff, J., Kloska, D. D., Patrick, M. E., Omalley, P. M., & Schulenberg, J. (2015). Predicting Young
Adult Degree Attainment by Late Adolescent Marijuana Use. Journal of Adolescent Health, 57(2), 205-211.
doi:10.1016/j.jadohealth. 2015.04.028.
Purpose: The purpose of this study was to assess whether infrequent and frequent marijuana use at age 19/20
years predicts receipt of educational degrees by the mid-20s, independent of confounding age 18 adolescent
risk factors. Methods: Data were from the Monitoring the Future study, an annual nationally representative
survey of high school seniors followed into adulthood. Thirteen cohorts (1990-2002) of high school seniors were
followed longitudinally to their mid-20s (n = 4,925; 54% female). We used logistic regression and propensity

52

 score matching with successive inclusion of age 18 risk factors and substance use to compare age 19/20
frequent marijuana users (six or more occasions in past 30 days) to nonusers, frequent users to infrequent users
(1-6 occasions), and infrequent users to nonusers on their likelihood of degree attainment by the mid-20s.
Results: Frequent marijuana users were less likely than infrequent users and nonusers to earn bachelor's
degrees, even after controlling for a host of age 18 risk factors (e.g., family socioeconomic background,
academic performance, educational expectations, truancy). However, these differences were reduced in
magnitude to statistical nonsignificance when we controlled for age 18 substance use. Across analyses, the
proportion reaching this educational milestone did not differ significantly between infrequent users and
nonusers. Conclusions: Results support a growing body of work suggesting that frequent marijuana use predicts
a lower likelihood of postsecondary educational attainment, and this difference may originate during secondary
school.
Nadelmann, E., & Lasalle, L. (2017). Two Steps Forward, One Step Back: Current Harm Reduction Policy and
Politics in the United States. Harm Reduction Journal, 14(1). doi:10.1186/s12954-017-0157-y.
Abstract: Harm reduction policies and attitudes in the United States have advanced substantially in recent years
but still lag behind more advanced jurisdictions in Europe and elsewhere. The Obama administration,
particularly in its last years, embraced some harm reduction policies that had been rejected by previous
administrations but shied away from more cutting edge interventions like supervised consumption sites and
heroin-assisted treatment. The Trump administration will undermine some of the progress made to date but
significant state and local control over drug policies in the US, as well as growing Republican support for
pragmatic drug policies, motivated in part by the opioid crisis, ensures continuing progress for harm reduction.
Pacula, R. L., Kilmer, B., Wagenaar, A. C., Chaloupka, F. J., & Caulkins, J. P. (2014). Developing Public Health
Regulations for Marijuana: Lessons from Alcohol and Tobacco. American Journal of Public Health, 104(6),
1021-1028. doi:10.2105/ ajph.2013.301766.
Abstract: Until November 2012, no modern jurisdiction had removed the prohibition on the commercial
production, distribution, and sale of marijuana for nonmedical purposes – not even the Netherlands.
Government agencies in Colorado and Washington are now charged with granting production and processing
licenses and developing regulations for legal marijuana, and other states and countries may follow. Our goal is
not to address whether marijuana legalization is a good or bad idea but, rather, to help policymakers understand
the decisions they face and some lessons learned from research on public health approaches to regulating
alcohol and tobacco over the past century.
Palamar, J. J., Ompad, D. C., & Petkova, E. (2014). Correlates of Intentions to Use Cannabis Among US High
School Seniors in the Case of Cannabis Legalization. International Journal of Drug Policy, 25(3), 424-435.
doi:10.1016/j.drugpo. 2014.01.017.
Background: Support for cannabis ("marijuana") legalization is increasing in the United States (US). Use was
recently legalized in two states and in Uruguay, and other states and countries are expected to follow suit. This
study examined intentions to use among US high school seniors if cannabis were to become legally available.
Methods: Data from the last five cohorts (2007-2011) of high school seniors in Monitoring the Future, an annual
nationally representative survey of students in the US were utilized. Data were analyzed separately for the 6116
seniors who reported no lifetime use of cannabis and the 3829 seniors who reported lifetime use (weighted Ns).
We examined whether demographic characteristics, substance use and perceived friend disapproval towards
cannabis use were associated with (1) intention to try cannabis among non-lifetime users, and (2) intention to
use cannabis as often or more often among lifetime users, if cannabis was legal to use. Results: Ten percent of

53

 non-cannabis-using students reported intent to initiate use if legal and this would be consistent with a 5.6%
absolute increase in lifetime prevalence of cannabis use in this age group from 45.6% (95% CI=44.6, 46.6) to
51.2% (95% CI=50.2, 52.2). Eighteen percent of lifetime users reported intent to use cannabis more often if it
was legal. Odds for intention to use outcomes increased among groups already at high risk for use (e.g., males,
whites, cigarette smokers) and odds were reduced when friends disapproved of use. However, large proportions
of subgroups of students normally at low risk for use (e.g., non-cigarette-smokers, religious students, those with
friends who disapprove of use) reported intention to use if legal. Recent use was also a risk factor for reporting
intention to use as often or more often. Conclusion: Prevalence of cannabis use is expected to increase if
cannabis is legal to use and legally available.
Rehm, J., Crépault, J., & Fischer, B. (2016). The Devil Is in the Details! On Regulating Cannabis Use in Canada
Based on Public Health Criteria Comment on "Legalizing and Regulating Marijuana in Canada: Review of
Potential Economic, Social, and Health Impacts". International Journal of Health Policy and Management,
6(3), 173-176. doi:10.15171/ijhpm.2016.114.
Abstract: This commentary to the editorial of Hajizadeh argues that the economic, social and health
consequences of legalizing cannabis in Canada will depend in large part on the exact stipulations (mainly from
the federal government) and on the implementation, regulation and practice of the legalization act (on
provincial and municipal levels). A strict regulatory framework is necessary to minimize the health burden
attributable to cannabis use. This includes prominently control of production and sale of the legal cannabis
including control of price and content with ban of marketing and advertisement. Regulation of medical
marijuana should be part of such a framework as well.
Rehm, J., & Fischer, B. (2015). Cannabis Legalization with Strict Regulation, the Overall Superior Policy Option
for Public Health. Clinical Pharmacology & Therapeutics, 97(6), 541-544. doi:10.1002/cpt.93.
Abstract: Cannabis is the most prevalently used drug globally, with many jurisdictions considering varying
reform options to current policies to deal with this substance and associated harm. Three policy options are
available: prohibition, decriminalization, and legalization, with prohibition currently the dominant model
globally. This contribution gives reasons why legalization with strict regulation should be considered superior to
other options with respect to public health in high income countries in North America.
Smith, R., Hall, K. E., Etkind, P., & Dyke, M. V. (2018). Current Marijuana Use by Industry and Occupation —
Colorado, 2014–2015. MMWR. Morbidity and Mortality Weekly Report, 67(14), 409-413.
doi:10.15585/mmwr.mm6714a1.
Abstract: The effects of marijuana use on workplace safety are of concern for public health and workplace
safety professionals. Twenty-nine states and the District of Columbia have enacted laws legalizing marijuana at
the state level for recreational and/or medical purposes. Employers and safety professionals in states where
marijuana use is legal have expressed concerns about potential increases in occupational injuries, such as onthe-job motor vehicle crashes, related to employee impairment. Data published in 2017 by the Colorado
Department of Public Health and Environment (CDPHE) showed that more than one in eight adult state
residents aged ≥18 years currently used marijuana in 2014 (13.6%) and 2015 (13.4%) (1). To examine current
marijuana use by working adults and the industries and occupations in which they are employed, CDPHE
analyzed data from the state's Behavioral Risk Factor Surveillance System (BRFSS) regarding current marijuana
use (at least 1 day during the preceding 30 days) among 10,169 persons who responded to the current
marijuana use question. During 2014 and 2015, 14.6% of these 10,169 Colorado workers reported current
marijuana use, with the highest reported prevalence among workers in the Accommodation and Food Services

54

 industry (30.1%) and Food Preparation and Serving (32.2%) occupations. Understanding the industries and
occupations of adults with reported marijuana use can help direct and maximize impact of public health
messaging and potential safety interventions for adults.
Thompson, K., Leadbeater, B., Ames, M., & Merrin, G. J. (2018). Associations Between Marijuana Use
Trajectories and Educational and Occupational Success in Young Adulthood. Prevention Science.
doi:10.1007/s11121-018-0904-7.
Abstract: Adolescence and young adulthood is a critical stage when the economic foundations for life-long
health are established. To date, there is little consensus as to whether marijuana use is associated with poor
educational and occupational success in adulthood. We investigated associations between trajectories of
marijuana use from ages 15 to 28 and multiple indicators of economic well-being in young adulthood including
achievement levels (i.e., educational attainment and occupational prestige), work characteristics (i.e., full vs
part-time employment, hours worked, annual income), financial strain (i.e., debt, trouble paying for necessities,
delaying medical attention), and perceived workplace stress. Data were from the Victoria Healthy Youth Survey,
a 10-year prospective study of a randomly recruited community sample of 662 youth (48% male; Mage = 15.5),
followed biennially for six assessments. Models adjusted for baseline age, sex, SES, high school grades, heavy
drinking, smoking, and internalizing and oppositional defiant disorder symptoms. Chronic users (our highest risk
class) reported lower levels of educational attainment, lower occupational prestige, lower income, greater debt,
and more difficulty paying for medical necessities in young adulthood compared to abstainers. Similarly,
increasers also reported lower educational attainment, occupational prestige, and income. Decreasers, who had
high early use but quit over time, showed resilience in economic well-being, performing similar to abstainers.
Groups did not differ on employment status or perceived workplace stress. The findings indicate that early onset
and persistent high or increasingly frequent use of marijuana in the transition from adolescent to young
adulthood is associated with risks for achieving educational and occupational success, and subsequently health,
in young adulthood.

55

 Appendix C: Comparative Review of State Laws Legalizing Regulated Marijuana Use
Comparative Review of State Laws Legalizing Recreational Marijuana Use
The information in this grid was adapted from the National Alliance for Model State Drug Laws (NAMSDL) document titled Marijuana: Comparison of
State Laws Legalizing Personal, Non-Medical Use. The National Alliance for Model State Drug Laws is funded by congressional appropriations and is the
non-profit successor to The President’s Commission on Model State Drug Laws. In coordination with the Office of National Drug Control Policy, the
NAMSDL drafts model drug and alcohol laws, policies and regulations, and analyzes existing state statutes.
Regulations corresponding with the states of Alaska, California, Colorado, Massachusetts, Nevada, Oregon and Washington were cross-referenced
against each state government website and updated accordingly. These states, which have legalized regulated marijuana use and set forth regulations
on state government websites, are outlined in this document. Washington D.C., which permits home cultivation only, has been excluded. It should be
noted that efforts to legalize marijuana production and use continue in many states, including in Maine, where a ballot initiative legalized marijuana
possession but regulations for the retail market have not yet been established.
Note: Information corresponding to a particular state/regulation may have not been available at the time this document was developed. Such instances
are indicated with ‘NA’.

56

 All information contained in this document is current as of April 30, 2018.

Comparative Review of State Laws Legalizing Regulated Marijuana Use
California

Colorado

Massachusetts

Nevada

Oregon

Washington

Effective Date

02/24/2015

12/10/2012

12/15/2016

01/01/2017

Regulating
authority

Marijuana
Enforcement
Division;
Department
of Revenue

Cannabis
Control
Commission

Nevada
Department
of Taxation

07/01/2015
Oregon Liquor
Control
Commission;
Oregon Health
Authority;
Oregon
Department
of Revenue

12/06/2012

Marijuana
Control
Board

11/09/2016
Bureau of Marijuana
Control;
Department of
Consumer Affairs;
Department of Food
and Agriculture;
Department of
Public Health

Examination
of law
enforcement
activity and
costs related
to marijuana
use in 20062007
compared to
2014-2015

Cannabis
Advisory Board
responsible for
examining
regulation of
marijuana/
marijuana
products

Overview

Alaska

Studies
required of or
requested by
regulating
authority

NA

Research/
evaluation of
implementation and
effect of the law,
including
determination of
impairment by use
of marijuana while
driving

57

NA

Investigate
influence of
marijuana on
driving ability

Washington
Liquor and
Cannabis
Control
Board

NA

Shared
Rationale

All states
represented
in this
document
have enacted
marijuana
legislation
into law and
developed
associated
regulation for
production,
sales and
consumption.

 Supply Chain

Alaska
Retail
Cultivation
Manufacturers/
Processors
Testing
Other

Excess limits and
repercussions

Home Cultivation

Colorado

Massachusetts

Nevada

Oregon

Washington

✓
✓

✓
✓

✓
✓

✓
✓

✓
✓

✓
✓

✓
✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓
NA

Alaska
Home cultivation
permitted
Maximum number
of plants/mature
per individual
Maximum number
of plants/mature
per household
Noncommercial
transfer limit

California

✓

✓
Microbusinesses

California

Transporters

Colorado

NA

Massachusetts

Distributors

Nevada

Wholesalers

Oregon

✓

✓

✓

✓

✓

6/3

6/NA

6/3

6/NA

6/NA

4/NA

12/6

6/NA

12/NA

12/NA

12/NA

12/4 (or 10
seeds)

1 oz. or 6
plants

1 oz.

1 oz.

1 oz.

NA

NA

NA

Plants and
marijuana
produced
>28.5 oz.
must be
secured by a
lock; not
visible by
normal

NA

Failure to keep
marijuana > 1
oz. locked up
within the
home
punishable by
a $100 fine/
forfeiture of
marijuana.

Unless an
agent of a
cultivation
facility, not
allowed to
cultivate
within 25
miles of a
licensed

NA

58

Shared
Rationale

Transporters

Washington

Not
permitted

Shared
Rationale
Home
cultivation is
allowed in all
states except
Washington.
In states where
home
cultivation is
allowed, plants
and marijuana
cannot be
visible from
public places
with unaided
vision and must
take place in an
enclosed and
locked area.
Homemade

 unaided
vision from a
public space.

Maximum amount
of residential
possession

NA

10 oz. of home
cultivated
marijuana; > 1
oz. of
marijuana
must be
secured by a
lock

NA

Alaska

California

Colorado

59
128 (includes
“standard” and
“limited” cultivation
facilities)

NA
NA

Manufacturing/
processers

11

NA

284

Testing licenses

3

NA

12

Other licenses

201 are currently
operational. 508
additional
applications are at
various stages of the
review process.

NA

8 operators;
9
transporters

Retail licenses

Current State of Market

Possession of
marijuana
produced by
the plants on
premises
where the
plants were
grown is
permitted.

retailer. 1st
violation
misdemeanor
fines up to
$600.

Cultivation/
producer
licenses

Massachusetts

NA

products may
be transferred
(not sold) to
another person
age 21 or older
in some states.

8 oz. useable
marijuana

Nevada

Oregon

Washington

529

NA

345

756

735

NA

23

1,465

Retail market
was not
operational at
the time this
document was
produced.

59

NA

19

1,572

NA

104
wholesalers

17

NA

345

917 producers/
processors;
37 transporters

Shared
Rationale

The number of
licenses
granted may
be restricted
by
municipalities.

 Amount of Marijuana Permitted for Personal Use

Alaska

California

Colorado

Massachusetts

Flower

1 oz.

28.5 gr.

1 oz.

1 oz.

Concentrated

7 gr.

8 gr.

8 gr.

5 gr.

Liquid
Solid
Maximum
amount in one
transaction
Maximum
amount for noncommercial
transfer

NA
NA

NA
NA

NA
NA

5,600 mg.
of THC

NA

NA

NA

Nevada

Oregon

Washington

1 oz.

1 oz. of
useable
marijuana in
a public
place

1 oz.

5 gr.

7 gr.

NA
NA

12.5% of 1
oz.
NA
NA

72 oz.
16 oz.

72 oz.
16 oz.

NA

NA

NA

NA

NA

1 oz

NA

1 oz., or 1/8
oz. if
concentrate

NA

NA

60

Shared
Rationale
Must be 21
years or older to
possess,
purchase or
consume
marijuana.
Products
permitted:
herbal, edible,
infused
products,
tinctures,
concentrates.

 Shared
Rationale
Must be 21
Up to $400 for Cannot possess
years or
providing false
or smoke
Cannot give
older to
Cannot
Illegal to
ID, $100 for
within 1,000
marijuana to
possess,
Class 2
Cannot
possess or
either open a
public
feet of a
anyone who
purchase or
misdemeanor
possess or
smoke
package
consumption;
school, day
is visibly
consumed
for an
smoke within
within a
containing
consumption
care or youth
intoxicated.
marijuana;
underage
a public or
public or
marijuana or
permitted on
center while
Cannot
not
person to
private school
private
consume
premises of
children are
import or
permitted in
buy or
or any
school or
marijuana "in
licensed
present; on the
export
public;
possess retail
correctional
any
view of the
retailer
grounds of, or
marijuana
cannot
marijuana.
facility.
correctional
general
designated for
within, any
from
possess or
facility.
public."
onsite
correctional
Oregon.
consume on
consumption.
facility.
federal
property.
Local government entities (city/town, county) may prohibit the operation of marijuana establishments or impose restrictions on
operations as a result of voter initiatives or local ordinances. The restrictions may impact retailers, manufacturers, and
cultivators. This includes limits to the number of establishments permitted and establishment of civil penalties for violations.

Overview of general
restrictions

Local control
Employer
restrictions
Specified
THC level
in blood
Specified
THC level
in urine
Possession
of
marijuana
while
operating

Driving During/After Use

Restrictions on Marijuana Consumption/Personal Use Regulations

Alaska

California

Colorado

Massachusetts

Nevada

Oregon

Washington

Employers may restrict or prohibit use, consumption, possession, and transfer of marijuana in the workplace.
>=5.0 ng/ml

NA

NA

NA

NA

NA

NA

NA

✓

✓

✓

61

NA

>=2 ng/ml

>=10 ng/ml

NA

NA

>=5.0 ng/ml

NA

NA

NA

NA

In all listed
states, it is
illegal to
operate a
motor
vehicle
under the
influence of
any
controlled
substance,

 vehicle is
illegal
Open
container
in vehicle
Exemption from
penalty provided by
law

including
marijuana.
May not
possess an
open container
of marijuana
while driving

NA

Application Process
Application Fees

Marijuana Establishments

Possession of
open
container may
result in fine
of up to $500

NA

NA

NA

Marijuana and marijuana products possessed and used in accordance with state laws are not subject to seizure
and may not be the basis for arrest.
Alaska

Background
check
90-day
turnaround
on
applications
Priority to
existing
medical
marijuana
establishme
nts

Passengers
may not
possess open
containers of
marijuana

California

Colorado

Massachusetts

Nevada

Oregon

NA

✓

✓

✓

✓

NA

✓

NA

✓

✓

✓

✓

NA

✓

NA

✓

✓

NA

Washington
Washington
State Liquor and
Cannabis Board
have no plan to
open the
window for new
retail or
producer
licenses as of
4/30/18.

New/Initial

$1,000

$1,000

$500

Cannot exceed
$3,000

$5,000

$250

$250

Renewal
Handler/
agent
permit

$600

NA

$300

NA

NA

NA

NA

$50

NA

$75-$250

NA

$75

$100

NA

62

Law
enforcement
officers may
base DUI
arrest on
observed
impairment.
Shared
Rationale

 Alaska

License Fees

Marijuana Establishments

Retail

California

Colorado

Massachusetts

Cannot exceed
$15,000

$5000

Cultivation/
producer

$1,000 - $5,000

Manufacturing/
Processer

$1,000 - $5,000

Testing

$1,000

Cannot exceed
$10,000

Distributor

NA

NA

Licensing and
renewal fees
based upon
size of
business,
$4,000$72,000;
$5,000 surety
bond

Cannot exceed
$15,000

Up to $4,900

63

Cannot exceed
$15,000

Nevada
Initial, max
fee $20,000;
renewal,
max fee:
$6,600
Initial, max
fee $30000;
renewal,
max fee
$10,000
Initial, max
fee $10000;
renewal,
max fee
$3,300
Initial, max
fee $15,000;
renewal,
max fee
$5,000
Initial, max
fee $15,000;
renewal,
max fee
$5,000

Oregon

Washington

$4,750

$1,480

$1,000$5,750
based on
size of
production

$1,480

$4,750

$1,480

$4,750

NA

NA

NA

Shared
Rationale

Licenses valid
for 1 year.
Massachusetts
began
accepting
applications
from
subgroups of
prospective
licensees on
April 17, 2018.
All other
license types
may start the
application
process
between May
1, 2018 and
June 1, 2018.

 Alaska

Establishment Restrictions

Marijuana Establishments

Licensee should be
21 years or older
Joint
medical/retail
marijuana
establishment
allowed

Criminal
conviction
restrictions

No record of
alcohol sales
No record of
unauthorized
substance sales

Other

California

Colorado

Massachusetts

Nevada

Oregon

Washington

✓

✓

✓

✓

✓

✓

✓

NA

NA

✓

✓

✓

NA

✓

Convicted of a
felony and
either (1) less
than 5 years
have elapsed
since conviction
or (2) person is
on probation or
parole for that
felony

No prior
record of
felony/no
substance
related
misdemeanor.

No prior
record of
controlled
substancerelated
felony in the
past 10
years/no
felony in the
past 5 years.

No prior
record of
felony (unless
it solely
involved the
distribution of
marijuana to
adults).

No
conviction
of any
"excluded
felony
offense",
no previous
license
revocation.

No
conviction
to state or
federal law
violations
relevant to
the
business.
No
specifically
set criteria.

NA

✓

✓

NA

NA

NA

NA

NA

✓

✓

✓

NA

✓

NA

NA

License
cannot be
granted to
habitual
users of
excess
alcohol or
other drugs

NA

No alcohol sales
within the last 5
years

Cannot be a
licensed
retailer of
alcohol or
tobacco

License
cannot be
granted to
law
enforcement

64

NA

NA

Shared
Rationale
All states
require
conduct
fingerprintbased
background
checks prior to
granting a
license. Most
states prohibit
previous
substancerelated
commercial
convictions
with the
exception of
Massachusetts.
Oregon
evaluates the
relevance of
prior criminal
records case
by case. Some
states are
working
toward
expunging
previous drug
related
offenses.

 Operational Restrictions and Requirements for Retail Establishments

Marijuana Establishments

Alaska

Distance requirements

Hours of operation

Customer must show ID

Insurance

Store shall not be
located in an
establishment with
liquor license
Substance shall not be
visible to the public

School:
500 ft.

Sales
Prohibited
between
5:00 am
and 8:00
am
✓

California

School: 600
ft.

Sales
prohibited
between
10pm and
6am
✓

Colorado

Massachusetts

School:
1000 ft.

School: 500 ft.

Varies by
municipality

✓

NA

NA

Nevada

School: 1,000 ft.;
community facility
300 ft.

Varies by
municipality

✓

Oregon

Washington

School:
1,000 ft.

School and
other
community
facilities that
are not
excluded for
adults: 1,000
ft.

Sales
allowed
between
7:00 am
and 10:00
pm
✓
Licensee
may
require an
affordable
general
liability
insurance.

Sales allowed
between
8:00 am and
12:00 am
✓
Licensee must
carry and
maintain
commercial
general liability
insurance and
if necessary,
commercial
umbrella
insurance.

May be
available
but not
required,
varies by
municipality

NA

NA

NA

✓

NA

NA

NA

NA

✓

NA

✓

NA

NA

✓

✓

NA

NA

NA

65

Shared
Rationale

 Operational restrictions and requirements

Marijuana Establishments

Maximum
amount of
THC per
serving size
Maximum
Servings per
package

Other
regulations

Alaska

California

Colorado

Massachusetts

Nevada

Oregon

Washington

< 5 mg THC

< 10 mg THC

< 10 mg THC

NA

< 10 mg THC

< 5 mg THC

< 10 mg THC

50 mg THC

NA

100 mg THC

NA

NA

50 mg THC

100 mg THC

May not be
located in
residential
areas;
delivery
allowed in
certain
circumstanc
es but only
between 8
am and
9pm.

Maximum
amount of
inventory for
retail: up to
four months of
their average
supplies. No
vending
machine or
drive through
Food requiring
temperature
control shall
not be infused
with
marijuana.

Handlers must
complete an
education
course and
pass a written
test; liquid and
solid edibles
must be
homogenized
to ensure
uniform
disbursement
of
cannabinoids

NA

All employees
shall be
residents of
Colorado.
Online sales
not allowed.

66

NA

Number of
retailers is
limited by
population of
county. A
county may
file a request
for additional
stores.

Shared
Rationale

 Labelling & Packaging
Advertising

Marijuana Establishments

Alaska
Cannot label products
to be appealing to
minors
Third-party-certified
child-resistant
packaging required
‘Contains marijuana’
symbol/text required
on packaging
Explanation of
warnings required on
packaging

California

Colorado

Massachusetts

Nevada

Oregon

Washington

✓

✓

NA

NA

✓

✓

NA

✓

✓

NA

NA

✓

✓

NA

✓

✓

✓

✓

NA

NA

✓

1) This product has intoxicating effects and may be habit forming. Smoking is hazardous to your health.
2) There may be health risks associated with the consumption of this product.
3) Should not be used by women who are pregnant or breast feeding.
4) For use only by adults 21 and older.
5) Marijuana can impair concentration, coordination, and judgment. Do not operate a vehicle or
machinery under the influence of this drug.

May not contain false
or misleading
information

✓

NA

May not promote
excessive
consumption

✓

NA

NA

May not depict
someone under 21
consuming marijuana

✓

NA

NA

✓

✓

✓

✓

✓

✓

✓
✓

NA

✓

67

NA

✓

✓

Shared
Rationale
General
consensus on
labeling:
Identification
of the
marijuana
cultivator/
manufacturer;
amount of THC
per
serving/packag
e; name and
logo of
cultivator; keep
out of reach of
children.
Some states
require
disclosure of all
pesticides
applied during
production and
processing.
Packaging
should be
certified to be
child resistant
by a third-party

 May not promote
transport across state
lines/target out of
state consumers

Cannot advertise on
TV/radio/print
unless…

May not claim
curative or
therapeutic benefits

NA

NA

NA

71.6% of
audience is
expected to
be 21 or
older

✓

NA

✓

✓

NA

70% of
audience is
21 or older;
outdoor
advertising
generally
prohibited

✓

68

85% of
audience is 21
or older

70% of
audience is 21
or older

NA

NA

✓

NA

✓

NA

NA

✓

firm. Package
should be
resealable in
case it includes
multiple
servings.
Packaging
should be
opaque.
Advertising
restrictions
vary, but many
states ban
advertising
within a certain
distance of
schools, limit
the amount of
signage outside
an
establishment
and restrict
online
marketing
and/or
marketing to a
mobile device.

 Monitoring/inspections

Marijuana Establishments

Alaska
Inspection of
physical
premises/establish
ment
Inspection by local
fire
department/code
inspector
Examination of
business and
financial records
Confirmation of
qualifications of
personnel
Testing
Tracking System:
Marijuana
Enforcement
Tracking Reporting
& Compliance
(METRC)
Tracking System:
Other
Other

California

Colorado

Massachusetts

Nevada

Oregon

Washington

✓

✓

✓

✓

✓

✓

✓

NA

✓

✓

NA

✓

NA

NA

✓

✓

✓

✓

✓

✓

✓

✓

NA

NA

NA

✓

NA

NA

Laboratory testing is required on samples of all marijuana or marijuana products which may include
potency testing (THC content), microbial testing, testing for pesticides and other contaminants.

✓

✓

✓

NA

✓

✓

NA

NA

NA

✓

NA

NA

NA

NA

NA

NA

NA

Secret shopper
program

69

NA

✓
NA

Shared
Rationale

The (METRC)
System is used
as a means to
record
inventory and
movement of
marijuana
through the
supply chain.
Other “Seed to
Sale” databases
may be used

 References

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